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PEDIATRICS 



THE 



HYGIENIC AND MEDICAL TREATMENT 



OF 



CHILDREN 



BY 

THOMAS MOEGAN ROTCH, M.D. 

PROFESSOR OF THE DISEASES OF CHILDREN, HARVARD UNIVERSITY 



ILLXJSTRATKD 



OCT 12 1B95 



^'J 



^0^ 



PHILADELPHIA 

J. B. LIPPINCOTT COMPANY 

1896 



\ 






Copyright, 1895, 

BY 

J. B. LippiNCOTT Company. 



Electrotyped and Printed by J. B. Lippincott Company, Philadelphia, Pa., U.S.A. 



TO 



:n^elsoi^ slater bartlett, 

IN RECOGNITION OF HIS INTEREST AND ENTHUSIASM 
IN PROMOTING 

THE STUDY OF PEDIATRICS. 



PREFACE. 



A FEW words are perhaps needed to explain what I have undertaken 
to do in the following pages, and the method of arrangement and classi- 
fication which has been employed. There has been no attempt to make 
such classifications as infectious and non-infectious diseases, because our 
knowledge of the former is increasing the number of that class so rapidly 
that for me it no longer constitutes a practical division for teaching. The 
book begins with a consideration of the infant at birth, and follows it 
through its various stages of development up to puberty. After dwelling 
rather more at length on normal development than is usual in works on 
pediatrics, the abnormal conditions are discussed. Beginning with the dis- 
eases which would naturally be met with in the early periods of life, and 
devoting considerable space to my observations on the blood of infants and 
of young children, the diseases of the different organs are then considered. 

With the exception of a few rare diseases of which it was impossible to 
get satisfactory types, the illustrations represent actual cases of my own, 
heretofore unpublished. The colored illustrations have received my closest 
attention, and the patients were seen personally with the artist, so as to 
insure accuracy. 

The establishment of milk-laboratories during the last three years has 
marked a new era in preventive medicine, and has made possible the scien- 
tific feeding of infants. As I believe that the medical treatment of the 
various abnormal conditions arising in infants is in the future to be largely 
dietetic rather than by means of drugs, I have given unusual prominence to 
the part of the work which is devoted to feeding. 

I have also endeavored, in conjunction with my colleagues in the Ameri- 
can Pediatric Society, to simplify the nomenclature of the various diseases, 
in order that physicians in different localities should by using identical 
names be the better able to aid one another in their investigations. A 
revision of the nomenclature of gastro-enteric diseases and of those of the 
mouth was especially called for on account of the changes which have 
followed our increasing knowledge of the etiology of these diseases. 

T. M. RoTCH. 

Boston, Mass., October, 1895. 



CONTENTS. 



DIVISION I. 

PAGE 

Introductory. — The infant at term 17 

Lecture I. — Toetal circulation 19 

Lecture II. — Vernix caseosa , . . 23 

Cord • 24 

Spine 26 

Neck 30 

Head ' 30 

Thorax 38 

Abdomen 44 

Pelvis 48 

Bladder 48 

Uterus 48 

Temperature 48 

Pulse 48 

Eespiration 48 

Height 49 

Weight 49 

Vitality 49 

Hands 49 

Feet 49 

Bone marrow 51 

Functions 51 

Blood 52 

Lymphatic system 52 

Urine 53 

Intestinal discharges 53 

DIVISION II. 

NOEMAL DEVELOPMENT. 

Lecture III.— Spine 55 

Neck 59 

Head 60 

Thorax 70 

Lecture IV. — Abdomen 77 

Temperature 94 

Pulse 94 

Respiration 96 

Height 96 

Weight 97 

Feet 105 

Bone marrow 107 

Skin 107 

vii 



Vlll CONTENTS. 

Lecture IV. — Continued. page 

Cord 110 

Functions 110 

Blood Ill 

Lymphatic system Ill 

Thyroid body Ill 

Urine Ill 

Intestinal discharges 117 

Infantile skeletons 118 

Normal infants 119 

Topographical anatomy of the early periods of life 120 



DIVISION III. 

HYGIENE OE THE NUESERY. 

Lecture V. — The nursery . . . • 125 

Intertrigo 132 

Seborrhoea capitis of infants 132 

Clothing . • 132 

Eeet and shoes 138 

Sleep 140 

Out-door air 140 

Nursery-maids 141 

Mouth 141 

School 142 

Importance of correcting defects of posture 142 

Vaccination 147 



DIVISION IV. 

FEEDING. 

Lecture VI. — The general principles underlying all methods of infant feeding . . . 153 

Lecture VIL — The first nutritive period 168 

1 . Maternal feeding 158 

2. Direct substitute feeding 209 

Lecture VIII. — The first nutritive period (continued) 214 

3. Indirect substitute feeding 214 

Lecture IX. — Indirect substitute feeding (continued) 230 

General remarks on substitute feeding 230 

Comparison of woman's and cow's milk 235 

Milk-laboratories . • 245 

Lecture X. — Home modification 276 

General remarks on artificial foods for infants 279 

Lecture XI. — The second and third nutritive periods 284 



DIVISION V. 
Lecture XII. — Premature infants 288 

DIVISION VI. 

GENERAL PRINCIPLES OF EXAMINATION AND TREATMENT. 

Lecture XIII. — Method of examining a sick child 318 

Drugs 319 



CONTENTS. IX 

DIVISION VII. 

THE BLOOD IN INFANCT AND CHILDHOOD. 

PAGE 

Lecture XIV. — Literature 329 

Nomenclature 330 

Blood-key 331 

Methods 332 

Chemistry 334 

Origin 336 

Fcetal blood 337 

The normal conditions of the blood in early life 339 

Lecture XV. — The pathology of the blood in early life 348 

Premature infants 348 

New-born infants 349 

Leucocytosis 350 

Leucgemia 351 

Oligocythgemia . . . . = 353 

Primary anaemia 355 

Chlorosis 355 

Anaemia progressiva perniciosa 356 

Anaemia infantum pseudo leuksemica (von Jaksch) 359 

Secondary anaemias 365 

Treatment of diseases of the blood 366 

Congenital syphilis 367 

Khachitis 368 

Lecture XVI. — The blood in individual diseases 370 

Typhoid fever 370 

Scarlet fever 371 

Measles 371 

Variola 371 

Diphtheria 372 

Pneumonia 372 

Broncho-pneumonia , 373 

Pneumonia and empyema 373 

Empyema 373 

Miliary tuberculosis 374 

Tubercular meningitis 374 

Hydrocephalus 375 

Chorea 376 

Nephritis 376 

Tubercular peritonitis 377 

Infantile atrophy 377 

Periostitis 378 

Scorbutus 379 

Icterus neonatorum 379 

Sclerema neonatorum 379 

Lecture XVII. —Parasites of the blood 380 

Literature of the blood in early life 398 

DIVISION VIII. 
DISEASES OF THE NEW-BORN. 

Lecture XVIII.— Maternal impressions 404 

The head 404 

The neck 416 

Lecture XIX.— The trunk 418 



X CONTENTS. 

PAGE 

Lecture XX. — The extremities 436 

General diseases 440 



DIVISION IX. 

Lecture XXI. — Diseases of the skin 455 

DIVISION X. 

SYPHILIS— EEYSIPELAS— THE EXANTHEMATA. 

Lecture XXII.— Syphilis 487 

Lecture XXIII. — Erysipelas . . 512 

Lecture XXIV. — Variola — Varicella , 517 

Lecture XXV. — Scarlet fever 532 

Lecture XXVI.— Measles 573 

Kubella • . • • 688 

DIVISION XI. 
DISEASES OF THE NEKVOUS SYSTEM AND THE MYOPATHIES. 

Lecture XXVII. — Introduction 590 

Lecture XXVIII. — I. Organic nervous diseases 594 

Brain 594 

Lecture XXIX. — Tubercular meningitis 603 

Lecture XXX. — Thrombosis of the cerebral sinuses 626 

Hydrocephalus 629 

Lecture XXXI. — Cerebral abscess 648 

Cerebral paralysis 648 

Athetosis 661 

Intra-cranial tumors 662 

Intra-cranial syphilis 668 

Idiocy 670 

Mirror writing ., 673 

Lecture XXXIL— Cord 676 

Myelitis 676 

Poliomyelitis anterior 676 

Paralysis caused by caries of the spine 688 

Hereditary ataxia (Friedreich's disease) 689 

Locomotor ataxia 689 

Syringomyelia 690 

Lecture XXXIII. —Brain and cord 691 

Multiple cerebro-spinal sclerosis 691 

Cerebro-spinal meningitis 692 

Lecture XXXiy. — Peripheral nerves 704 

Neuritis 704 

Paralysis of the new-born 706 

Neuralgia 709 

Lecture XXXV. — IL Nervous diseases presumably organic 711 

Chorea , 711 

Epilepsy 724 

Insanity ,, " . 731 

Lecture XXXVI. — III. Functional nervous diseases. (1) Probably central ... 732 

, Hysteria 732 

Hypnotism 735 



CONTENTS. XI 

Lecture XXXVI. — Continued. page 

Catelepsy 735 

Simulated diseases 735 

Insolation 736 

Concussion 738 

Temporary amnesia 739 

Temporary aphasia 739 

Arrested psychical development 740 

Ketarded speech 740 

Headaches 741 

Vertigo 743 

Sensitive spine 744 

Tetany 744 

Pavor nocturnus (central) 745 

Lecture XXXVII. — IV. Functional nervous diseases. (2) Eeflex 746 

Pavor nocturnus (peripheral) 746 

Dental reflex 746 

Reflex nystagmus 747 

Reflex of the ear , 747 

Reflex of the larynx , 747 

Paroxysmal gasping 749 

Reflex of the lung 750 

Reflex cough 751 

Reflex of the heart 751 

Reflex of the stomach 752 

Reflex of the bladder 752 

Reflex of the vagina 752 

Reflex of the rectum 752 

Lecture XXXVIII. — Convulsions 754 

Tremor 762 

Lecture XXXIX. — The myopathies 763 

Progressive muscular atrophy 763 

Pseudo-hypertrophic muscular paralysis 768 

Myotonia congenita (Thomsen's disease) 773 

DIVISION XII. 

DISEASES OP THE MOUTH, NOSE, NASO-PHARYNX, AND PHARYNX. 

Lecture XL. — Stomatitis catarrhalis 776 

Stomatitis herpetica 779 

Stomatitis ulcerosa 781 

Stomatitis mycetogenetica 784 

Glossitis 793 

Microglossia 794 

Macroglossia 794 

Difficult dentition 795 

Lecture XLI. — Diseases of the nose, naso-pharynx, and pharynx 801 

Lecture XLII. — Diphtheria 821 



DIVISION Xlll. 

DISEASES OF THE (ESOPHAGUS, STOMACH, AND INTESTINE. 

Lecture XLIIL— Introduction 834 

(Esophagus 834 

Stomach and intestine 836 



XU CONTENTS. 

PAGE 

Lecture XLIY. — Diseases of the stomach 840 

Lecture XLV. — Diseases of the intestine 858 

DIVISION XIV. 
Lecture XLVI. — Diseases of the liver, pancreas, spleen, and peritoneum 914 

DIVISION XV. 

Lecture XLVII. — Diseases of the kidneys, bladder, and genitals 927 

Kidneys 927 

Supra-renal capsules , 940 

Bladder 942 

Genitals 943 

DIVISION XVI. 
DISEASES OF THE LAKYNX, TKACHEA, LUNGS, AND PLEUKA. 

Lecture XLYIII. — Laryngospasmus 949 

New growths 949 

Foreign bodies - 950 

(Edema 950 

Laryngitis 951 

Lectukk XLIX.— Diseases of the lungs 954 

Bronchitis 954 

Broncho-pneumonia 962 

Atelectasis 979 

Lobar pneumonia 980 

Gangrene 986 

Tuberculosis • . . . 993 

Pertussis 998 

Asthma 1004 

Periodic catarrh 1005 

Lecture L. — Diseases of the pleura 1007 

DIVISION XVII. 

DISEASES OF THE HEAKT AND PERICAEDIUM. 

Lecture LI. — Diseases of the heart 1019 

Lecture LII. — Diseases of the pericardium ; . • 1046 

DIVISION XVIII. 

UNCLASSIFIED DISEASES. 

Lecture LIII. — Ehachitis 1065 

Scorbutus 1075 

Eheumatism 1080 

Purpura 1086 

Diabetes 1088 

Tuberculosis 1089 

Epidemic influenza 1092 

Diseases of the thyroid gland 1095 

Diseases of the cervical lymph-glands 1101 

Parotitis . , 1104 

Diseases of the ear 1105 



PEDIATRICS. 



DIVISION I 

INTRODUCTORY-THE INFANT AT TERM. 



LKCTURE I. 

INTRODUCTORY.— THE FCETAL CIRCULATION. 

Gentlemen, — We are to-day beginning the study of a branch of 
medicine which will be of the greatest practical importance to you in your 
future careers. Those of you who enter into general practice will at once 
be called upon to treat infants and children. The proper appreciation of 
the sensitive temperaments and needs of this class of patients will be of 
great aid in successfully establishing your practice among those whose favor- 
able opinion may make or mar your professional success. The difficulties to 
be surmounted in correctly diagnosticating and treating young children are 
far greater than those which you encounter in adult life. The reason for 
this is that for adult cases you have some standard by which you can be 
guided, being yourselves adults. What standard, however, have you for 
the feelings and sensitive organization of the child? None within your- 
selves ; it must all come from long and patient observation, with its re- 
sulting experience. The mere knowledge that certain diseases exist, and 
the usual methods of diagnosticating them, prove to be very inadequate 
when we are brought face to face with a sick and fretful child, or with an 
infant who is unable to describe its symptoms. Much additional knowledge 
is needed to enable us to understand the variety of symptoms which may 
arise in the same disease according to the age and individuality of the 
patient. It is now well recognized that there is a necessity for making a 
special study of children beyond what is learned in the general clinical study 
of adults. As our knowledge advances, we learn to appreciate that the 
various methods of treatment must be modified to correspond not so much 

2 17 



18 PEDIATRICS. 

to the special disease as to the special group of symptoms brought about by 
the age of the individual and the phase of its development. In studying, 
then, the different stages of development in children, we are in reality 
acquiring an alphabet, which when once thoroughly mastered will enable us 
to read the otherwise obscure language presented to us for translation by the 
various diseases of early life. The proper method of learning to understand 
sick infants and children is first to notice their peculiarities in health and to 
follow these peculiarities through the different stages of their development 
up to puberty. Thus, a pulse which would indicate an abnormal condi- 
tion in the adult, or a convulsion which would be of serious import in the 
older subject, may often be but physiological or of slight consequence in the 
child. In fact, there are a large number of physiological and anatomical 
truths concerning the young the knowledge of which will simplify to a 
great degree otherwise almost insurmountable difficulties in diagnosis. The 
lack of this preliminary training, this alphabet, places the student who is 
endeavoring to understand diseases in children, in the position of attempt- 
ing to read without having first learned his letters. It is our province in 
this course of lectures to begin with the human being at birth, to study it as 
it is presented to us in the early hours of life, and to follow it in its develop- 
ment during the periods of infancy and childhood up to the age of puberty. 
It then approaches so nearly in its development to the adult that its diseases 
assume the type of adolescence, and your studies carry you into the province 
of general clinical medicine. For purposes of simplicity, we speak of infants 
and children, the anatomical and physiological conditions being sufficiently 
apparent to warrant this distinction between them. The period of infancy 
is usually spoken of as covering about the first two years of life. Its most 
distinctive features are presented in the first twelve months, the second year, 
month by month, rapidly approaching the conditions which exist in child- 
hood. The second year, however, is influenced to such a degree by the 
various growing functions and tissues that its picture both in health and 
in disease resembles more closely the infant than the child. Childhood is 
empirically reckoned from the end of infancy to puberty, or the beginning 
of adolescence. A distinction must be made between the sexes, the girl 
becoming a fully-developed woman some years before the boy becomes 
a man. The age of puberty is usually reckoned as beginning from the 
twelfth to the fourteenth year. Much latitude as to age, however, must 
be given for the special idiosyncrasy of the individual, and also for the 
climate, as it has been found that children who live in a warm climate 
arrive at the age of puberty much earlier than those who are exposed to 
the lower ranges of temperature. In taking the period of birth as a start- 
ing-point for our studies we must not overlook the fact that it is simply a 
stage of development with which we are dealing, and not a perfected being. 
The better, therefore, you understand the evolution of the embryo to the 
infant, the better will you be prepared to appreciate the evolution of the 
infant to the child and of the child to the adult. It is especially important 



FCETAL CIRCULATION. 19 

to understand the stage of development which exists just before birth, for 
on this depends the knowledge whether we have a physiologically and 
anatomically normal being before us, or one that is abnormal. Remember 
that disease does not merely mean a pathological change in the tissues, but, 
as is especially well exemplified in the infant, may simply mean a retarda- 
tion or arrest of development. Thus, what would be perfectly normal 
anatomically at the seventh month of intra-uterine life may at birth be 
abnormal, and hence constitute a disease. In like manner what may be 
normal at birth may if it persists into the second and third weeks become 
an abnormal condition. Disease, therefore, is a relative term. We may, 
however, simplify our classification of diseases by adopting tsvo broad 
divisions corresponding to the changes which take place during intra- and 
extra-uterine life. By congenital diseases we mean those resulting from 
changes occurring during intra-uterine life. These may arise from an 
arrest of development or from a continuation of normal intra-uterine con- 
ditions beyond the usual period of their cessation ; also those which are 
caused by pathological processes such as inflammation. By acquired, we 
mean a pathological condition of existing tissues occurring after birth, and 
without regard to the stage of development. 

If we thoroughly understand the anatomical conditions existing just 
before birth, we can intelligently examine the young human being as it 
emerges from the uterus, and can judge in the early days of its existence 
whether we have under our care a normal infant or one that is to need 
special treatment. 

FCETAL CIRCULATION.— The chief anatomical change which takes 
place at birth is the transition from the intra-uterine circulatory mechanism 
to a form adapted to extra-uterine life ; in other words, from the oxygena- 
tion of the blood through the placenta to the same process carried on by 
the lungs. A general knowledge of the foetal circulation is, then, evidently 
of considerable importance for you to acquire, especially when you consider 
that a large proportion of the cases of congenital heart disease w^hich you 
will be called upon to diagnosticate is represented by perfectly normal pre- 
natal conditions, such as absence of the ventricular septum, an open ductus 
arteriosus, or a patent foramen ovale. 

This diagram (Diagram 1) represents the course of the (red) oxygenated 
blood from the placenta to the infant, and that of the darker (blue) deoxi- 
dized blood from the infant back to the placenta. We must consider that in 
the foetus the lungs are in a collapsed, inert condition, performing no part in 
the foetal economy, but remaining quiescent until called upon to perform their 
special function at birth. The true lung of the foetus, therefore, is repre- 
sented by the placenta of the mother. It is here that the blood is oxygen- 
ated, and is carried by means of the umbilical vein directly through the 
umbilicus of the foetus to tlie liver, as seen in the diagram. In the liver, the 
umbilical vein divides into three branches : (1) the smallest, carries the blood 
directly to the liver tissue, whence it is retnrned as in the adult to the inferior 



20 PEDIATRICS. 

cava by the hepatic veins ; (2) the largest portion meets and mixes with the 
blood from the portal system, and is distributed with it to the liver ; (3) 
the remaining portion is carried, by a vessel called the ductus venosus, 
directly to the inferior cava, where it meets the deoxidized blood from the 
lower extremities, mixes with it, and is carried to the right auricle : here, 
instead of passing as in the adult into the right ventricle, it is directed 
by a membrane, called the Eustachian valve, through an opening between 
the two auricles, called the foy^amen ovale, into the left auricle. It then 
passes into the left ventricle through the mitral valve, and thence through 
the aortic valve into the aorta. The greater part of the blood-current is 
then carried by the carotid and subclavian arteries to the head and upper 
extremities, where, after doing its work in vitalizing the tissues and taking 
up their waste (a small portion also passing, as usual, into the descending 
aorta), it is returned as deoxidized blood through the veins to the superior 
cava into the right auricle, thence through the tricuspid valves into the 
right ventricle, and up through the pulmonary artery, where a small portion 
is distributed as usual to the lungs, while the remaining portion is carried 
directly over to the descending aorta by a vessel called the ductus arteriosus. 
It here mixes with the small portion of oxygenated aortic blood mentioned 
above, and passes down the aorta, being distributed on its way, as in the 
adult, until it reaches the internal iliac arteries. From these arteries it is 
carried, by branches called the umbilical arteries, through the umbilicus back 
to the cord and placenta. Thus, by simply referring to this diagram, we can 
tell at a glance which part of the young infant should be most developed, 
and the reasons for it. A noticeable point of clinical interest, in tracing the 
course of the foetal circulation, is that the fresh oxygenated blood is mainly 
carried to the liver, head, and upper extremities, while the devitalized blood 
is distributed to the thorax and lower extremities. We should therefore 
expect, and we shall find it to be true, when we examine a normal new-born 
infant, that the head is larger than the thorax, that the abdomen is prominent 
from containing the large liver, and that the legs are insignificant and 
poorly developed. 

When the placental circulation is cut off, an increased amount of blood 
is carried by the pulmonary artery to the lungs, and by degrees the foetal 
circulation is replaced by that of extra-uterine life. 

The ductus venosus and ductus arteriosus become fibrous cords. 

The Eustachian valve disappears. 

The foramen ovale closes. 

The umbilical vein and umbilical artey-ies become obliterated, with the 
exception of the lower parts of the latter. 

All these changes, however, do not take place simultaneously, which is a 
point to be remembered in making a differential diagnosis of cardiac disease 
during the first ten days of infancy. We should therefore endeavor to bear 
in mind at about what time these changes take place. The following table 
will, I think, assist you in accomplishing this : 



Fa:TAL CIRCULATION. 21 

TABLE 1. 

POST-NATAL CHANGES OF FCETAL CONDITIONS. 

Ductus Venosus. — The ductus venosus becomes a fibrous cord in the fissure of the ductus 
venosus in from two to five days. 

Eustachian Valve. — The intra-uterine function of the Eustachian valve practically 
disappears at once at birth, but its remains can be found for an indefinite period, as you 
see in this heart dissected by Dr. F. Dexter (Fig. 19, facing page 74). 

Poramen Ovale. — The foramen ovale usually closes about the tenth day, but the upper 
part sometimes never closes. The closed foramen ovale is seen in this same heart 
dissected by Dr. F. Dexter (Fig. 19, facing page 74). 

Ductus Arteriosus. — The ductus arteriosus is about 1.5 cm. (| inch) long, has a diameter 
of about .25 cm. (^ inch), and is usually, so far as being pervious to the blood is con- 
cerned, obliterated in from four to ten days. Its remains, forming a fibrous cord 
connecting the pulmonary artery and the aorta, can be seen in this heart dissected by 
Dr. F. Dexter (Fig 20, facing page 74). 

Umbilical Vein. — The umbilical vein becomes the round ligament of the liver, and is 
obliterated in from two to five days. As pointed out by Jacobi, it differs from the 
arteries very much less than is usual with the veins and arteries in other parts of the 
body. Its muscular layer is very large and strong. 

Umbilical Arteries. — The umbilical arteries in their upper parts become obliterated 
in from two to five days, forming the anterior true ligaments of the bladder, while 
the lower parts remain pervious and form the superior vesical arteries. The umbilical 
arteries are usually thick and strong, owing to the great development of their muscular 
layer. 

Thus you will observe that durmg the first two weeks of infancy we 

Fig. 1. 




Heart, natural size, at two days. A marks the aorta ; PA marks the pulmonary artery ; DA marks the 

ductus arteriosus. 

may have conditions existing physiologically which after that time would 
become pathological, and hence, to be well grounded in the diagnosis of 



22 PEDIATRICS. 

disease in the infant, we must appreciate the importance of these facts and 
retain them for future use. 

The heart is the organ on which, from the importance of its function to 
the system in general, our interest is at once centred at birth. It is well, 
therefore, for you to know exactly how it should look normally, and how 
large it should be. 

This heart (Fig. 1, page 21) was taken from an infant two days old ; it 
is of normal size, and shows the ductus arteriosus connecting the aorta and 
the pulmonary artery. 

This metallic injection of the heart and blood-vessels of the foetus (Fig. 
2), made by Dr. S. J. Mixter, shows you very clearly the ductus arteriosus 
and the ramifications of the various branches of the pulmonary artery and 
the aorta. 

You must, of course, remember that where a cavity existed in the heart 
and vessels of the foetus, the metal preparation shows a solid mass. Thus 
you can learn exactly the appearance of the inner surfaces of the right and 
left auricles and ventricles, the pulmonary artery, the ductus arteriosus, 
and the aorta. 



Fig. 2. 




-> 



:Metallic injection of foetal heart and blood-vessels : A marks the aorta ; PA marks the 
pulmonary artery ; D A marks the ductus arteriosus. 



THE INFANT AT TERM. 



23 



I.ECTURK II. 

THE INFANT AT TERM. 

Yernix Caseosa— Cord — Spine — Neck— Head — Thorax — Abdomen — Tempera- 
ture — Pulse — Kespiration — Height — Weight — Vitality — Hands — Feet — 
Bone Marrow — Functions — Blood — Lymphatic System — Urine — Intes- 
tinal Discharges. 



By the infant at term we mean one that has been born at the termina- 
tion of what is considered the usual period of pregnancy, two hundred and 
eighty days. 

I shall by showing you actual cases of normally developed infants in the 
early days of life endeavor to teach you what conditions are important for 
you to remember as distinguishing marks from the abnormal cases which I 
shall present for your inspection later. 

This infant (Case 1), one hour old, represents the appearance of a normally developed 
foetus when it first emerges from the uterus. The reddened skin, as you see, is covered in 
many parts thickly by a substance 

made up of the contents of the am- Case 1. 

niotic sac, in which the foetus has 
been floating, and of the excretion 
of the sebaceous glands. This sub- 
stance, which is called the vernix 
caseosa, must be removed in order 
that we may study the infant as it 
normally appears in the first stage 
of its existence. It is evident, how- 
ever, that the infant is born with 
highly developed sebaceous glands, 
which at times produce a secretion 
so excessive as to be difficult to 
get rid of. In certain rare cases also 

this sebaceous matter is so universal and so impenetrable as to constitute a disease of serious 
import, and at times even to cause death. Infants are also born with the skin almost entirely 
free from the vernix caseosa, so that it is not necessarily present, and in fact I have had 
to wait for some time before I could get a subject which would present this condition 
sufficiently marked for illustration. You will also notice the dark faecal discharge, called 
meconium, which is coming from the anus, and which is so characteristic of the earlv hours 
of life. 

This infant was shown to you merely to represent the vernix caseosa, while what we 
are especially called upon to deal with is the new-born infant freed from its amniotic cover- 
ing and with its entire surface prepared for our inspection. 

For the purpose of illustrating this condition I will now show you 
another infant (Case 2, Frontispiece) : 

A male, two days old. Its birth-weight was 3800 grammes (8.} pounds) ; its length is 
480 mm. (19 inches) ; the circumference of its head is 34 cm. (13^- inches) ; the circumference 




Infant immediately after birth, covered almost entirely 
with the vernix caseosa, and having a discharge of me- 
conium. 



24 PEDIATRICS. 

of its thorax is 33 cm. (13 inches) ; and the circumference of its abdomen is 35.5 cm. (14 
inches). 

The infant has just been bathed, and presents the color of a healthy 
skin reacting normally to the temperature of the water, 36.6° C. (98° F.), 
and that of the room, 21.1° C. (70° F.). I have chosen this particular case 
as representing best what a strong healthy infant should look like. I shall 
presently show you that it is somewhat larger than the average infant at 
two days. In reality, however, so far as my experience goes, the size of 
this infant corresponds very closely to that of most healthy infants that are 
born outside of hospitals in families who live in comfortable homes of their 
own and in healthy localities. The delicate pink of the skin, the well- 
rounded body and limbs, the vigorous cry, the warm extremities, already 
beginning to move with activity, and the strong grasp of the little hands, 
all justify me in showing you what at this age may be looked upon as the 
picture of health. 

The hair at birth is often thick, dark, and quite long, perhaps 2 to 5 
cm. (1 or 2 inches) ; but we also frequently find the hair to be short, fine, 
some shade of light brown, small in amount, and, as you see on examining 
this infant's head, the temples to be bald and the hair to come down to a 
rounded point on the forehead. The eyes are almost always as you see in 
this case, half open when awake, expressionless, and of a dull grayish blue. 
Notice also what your study of the foetal circulation explained so well, the 
large head in comparison with the thorax, the arms more rounded and large 
in proportion to the legs, and the prominent abdomen. 

CORD. — I have had the dressing removed in order that you should be 
able to study the cord minutely. You see how it is already drying up 
preparatory to falling off on the sixth or seventh day. The cord in health 
does not often receive much attention from the physician, and usually it is 
familiar in its appearance to the nurse only. Yet it is quite important for 
you to know how it should look normally up to the day when it separates 
from the umbilicus, for at times you are called upon to decide whether it is 
diseased, and unless you are familiar with it in health your opinion will not 
be of much value as to whether you have an abnormal condition before you. 
You see the slightly reddened areola where it joins and is to part from the 
abdominal wall. The three vessels are easily picked out, and differ in color. 
The two dark, almost black, lines twisting in and out around the single 
greenish-yellow and broader line are the umbilical arteries. The flat yellow 
line is what remains of the umbilical vein. 

Palpation, percussion, and auscultation show that the heart has about the 
same proportionate position in reference to the lungs as is found in the adult, 
but that the liver occupies much more space, coming fully 1 to 2 cm. (J to 
1 inch) beloAv the edge of the ribs in the right hypochondriac and the epi- 
gastric regions, and encroaching on the lung-space in the right back to the 
extent of fully one rib and interspace. The testicles have descended, and 
the bladder, which is evidently full of urine, presents an area of dulness of 



THE INFANT AT TERM. 25 

about 2 cm. (1 inch), just above the pubes in the median line. This cor- 
roborates the important fact, to which I shall refer later, that the bladder is 
an abdominal rather than a pelvic organ in the infant and the young child. 
The dull area of the spleen corresponds in its position to that found in the 
adult, but is scarcely perceptible. 

I should like you to retain carefully in your minds this perfect picture 
of a human being at term, for it is the central point from which will diverge 
many interesting conditions of the later and higher development which I 
have undertaken to elucidate for you in these lectures. 

We shall next study more in detail certain anatomical and physiological 
truths relating to the infant at term, but having reference to what is usually 
found to exist in the average infant rather than in the individual. 

The figures which I shall present to you must necessarily be accepted 
in a general way, and will often be found lacking in exactness simply 
because there are so many exceptions to general rules taken from large 
numbers of cases. In my own experience, however, they have proved to 
be so near to the truth as to be exceedingly valuable in my clinical work. 
1 have for many years had them verified in a number of large clinics and 
in my private practice, and they at least form a very fair basis for you to 
start with. 

I shall now call your attention in a general way to a number of new- 
born infants of various weights and degrees of development, and show you 
that there are certain characteristics common to them all and corresponding 
to the period of birth. I am especially indebted to Professor Thomas 
Dwight for the assistance which he has given me through his own original 
investigations and for his verification of my clinical and anatomical work, 
the results of which I shall now lay before you. You must pardon me if, 
for the purpose of impressing upon you what I consider of absolute impor- 
tance, I seem to repeat unnecessarily at times. 

Remember also that I do not attempt nor deem it wise to give you 
the complete anatomy and physiology of the period of life we are studying. 
I shall merely pick out for your use the practical points in these periods 
which will aid you in clinical diagnosis and treatment. The great impor- 
tance of thoroughly understanding the normal anatomy and physiology of 
human beings before attempting to deal with the morbid conditions which 
arise in them is now so well recognized that no preliminary remarks are 
needed to show how vital to all advance in clinical medicine is the proper 
reading of anatomical and physiological truths. There are several points in 
the anatomy and physiology of the new-born infant which would be better 
understood if the fact were borne in mind that in many respects the body 
at this age is more adapted to its intra-uterine life and to its means of 
exit into the external world than to the conditions which surround it in 
extra-uterine life. 

Notice these infants a few hours old, as they are held up for your 
inspection by the nurses. By having one with its face (Case 3) and the 



26 PEDIATRICS. 

other with its back (Case 4) towards yoii^ you can easily follow what I am 
about to tell you of the anatomical conditions characteristic of this early 
period of life. 

This infant's (Case 3) face is, as you see, swollen and the features are out 
of shape. This condition is not uncommon at birth ; it comes from pressure, 
and will soon pass off. 

The cord, you see, has already been dressed with cotton. 

The anatomical points so evident at birth as belonging to intra-uterine 
life, and the peculiarities of the foetal circulation, I have already dwelt 
upon, and I shall now point out to you the characteristics of the new-born 
trunk. This is egg-shaped, the larger end being below. The pelvis 
as a region hardly exists, and the thorax is very small when compared 
with the large abdomen. The latter is very large, owing to the dispropor- 
tionate development of the liver, presumably a great organ of nutrition 
during foetal life. A striking peculiarity is the almost complete absence 
of shoulders, which with the arms are relatively insignificant outgrowths 
from the sharp end of the egg. I shall later consider the thorax in 
detail, but I may now mention that it is evident that its small size, its 
want of solidity, and the slight development of the pectoral and shoulder 
muscles indicate that its action in respiration must be very different from 
that in adult life. 

The greatest breadth of the trunk is in the region of the lower ribs. 

During intra-uterine life, and especially at the time of delivery, great 
flexibility and compressibility are requisite. Respiration has not yet oc- 
curred, and the assimilation of nutriment for the growth of the body and 
for preparing the rudiments of future organs has been the function most 
actively employed. When, therefore, we study the new-born infant we 
must remember that we see it at an essentially transitional stage. Adapta- 
tions, the marked utility of which is past, still persist, and new functions 
^re carried on with very imperfect apparatus. These general principles 
having been stated, I can now discuss more in detail the spine. 

SPINE. — One of the most beautiful of anatomical preparations is this 
cleanly dissected spine of an infant at birth suspended in a jar of alcohol 
(Fig. 3). 

Owing to the removal of the other parts, its shape (if there be any at this 
age) is lost, but it is excellent for the study of the component parts. It is a 
wonder of lightness and flexibility. There is little bone and much cartilage 
and fibrous tissue. It can be twisted and bent at will in any direction. 
Looked at critically, it appears relatively broader in proportion to its length 
than does the adult spine. The height of the vertebrae is relatively less, and 
appears even less than it is, from the fact that the broad, narrow, tony 
nucleus of the vertebral body, which catches the eye, does not represent the 
whole thickness of the body, as it is embedded in cartilage. 

At this early stage of development the whole column is cartilaginous, 
with the exception of the nuclei of the bodies of the vertebrae and those of 



THE INFANT AT TERM. 



27 



the laminse on either side^ forming a small ^ig. 3. 

portion of the body and the beginning 
of the arch. 

The time of the consolidation of the 
bodies is not accurately known, but this 
will be spoken of in the lecture on de- 
velopment. 

In the young embryo, the proportion 
of the neck in the movable part of the 
spine is greater than that of the loins, a 
condition which is reversed in the adult, 
where the neck is less, being a little over 
one-fifth, and the loins a little less than 
one-third. In fact, the proportions of 
the spine change considerably from an 
early period of intra-uterine life to that 
of the perfected adult condition. At 
birth, however, the change has progressed 
sufficiently to make these two parts very 
nearly equal. The union of the laminae 
to form the spine begins in the upper 
part of the spine sooner than in the lum- 
bar region. Throughout the greater part 
they are nearly united, and in some places 
are quite joined, at birth. 

I mention these details not expecting 
you to remember them, but for future 
reference in cases where the spine is in- 
volved in diagnosis, and perhaps for in- 
telligent orthopedic treatment. What I 
am about to tell you will also be valuable 
in directing the care of the normal child 
in regard to its sitting and standing. 
You see on examining these infants 
(Cases 3 and 4) how pliable and easily 
bent in all directions is the spine, and 
how their backs can be made to take 
almost any curve. 

You will also understand better what 
I am about to say if you will examine 
closely this diagram of three spinal curves, 
representing (1) the natural curve at 
birth, (2) the curve which comes espe- 
cially in the cervical region when the 
infant has learned to sit up and the superincumbent head has to bo 




Dissection of the spftie and pelvis in a new- 
born infant. Warren Museum, Harvard Uni- 
versity. 



Hip- 



28 



PEDIATRICS. 



ported, and (3) the additional dorsal and increased lumbar curves which 
appear when the child stands and walks, and which correspond to those of 
the adult condition. 



Infant at birth. 



Diagram 2. 

SPINAL CURVES. 

Infant sitting. 



Infant standing. 



front — ► 




(1) (2) (3) 

C represents cervical curve ; D represents dorsal curve ; L represents lumbar curve ; S represents 

sacral curve. 

A great deal has been written about the curves of the spine in new-born 
children, and their appearance in the embryo. Much of this literature is 
a monument of wasted ingenuity. The truth is, that at birth, when the 
child is lying in what may be called its normal position, — that is to say, on 
its side, with the head flexed and the thighs drawn up, — the whole spinal 
column presents one long concavity from the atlas to the coccyx, the front 
of Avhich is subdivided into two curves by the slight projection of the 
promontory of the sacrum. Above this there is a tolerably regular con- 
cavity. The head can be thrown back so as to make a slight convexity in 
the neck, and by bringing the knees against the table (the infant being on 
its back) the lumbar region will spring forward ; but the former of these 
positions is rather unnatural, and the latter impossible without assistance. 



THE INFAXT AT TERM. 29 

The concavity of the thoracic curve remains to be discussed, and this is the 
only one of the curves above the sacrum that can be said to have any real 
existence at this age. When, however, we analyze more fully the existence 
of this curve, we begin to doubt whether it is after all so very real, for, 
though the sternum and ribs have some retaining influence, it is possible 
by bending the body backward to obliterate this curve also. We can then 
consider the part of the spine above the sacrum as essentially a fibrous and 
cartilaginous rod with a number of separate disks of bone embedded in it at 
different places. The extent of the movements possible at birth, both in the 
dissected spine and in the whole body, is very remarkable, as is shown by 
these few experiments. The first was on the body of a female child at birth 
large and ^'ell nourished. The abdominal viscera having been removed, it 
was very easy to bend the head back so as to touch the buttocks. The head 
and extremities were then removed, the ribs cut near the junction of the 
cartilages, and the spine and pelvis roughly cleaned. It was then possible, 
by some straining, to bend the spine backward so that the atlas and coccyx 
met. It was, however, easy to bend it backward so as to make an arch, the 
atlas and coccyx resting on the table. It was noticed that the middle part 
of the spine was the most flexible, the dorsal concavity of after-life being 
easily changed into a convexity. The lumbar region appeared to be more 
pliant than the cervical. The point of greatest motion was apparently 
bet\\"een the eleventh and twelfth dorsal vertebrae. The whole spine, with 
each of the cervical, dorsal, and lumbar regions, bends forward with about 
the same readiness that it does backward. It may at first appear sm^prising 
that it does not bend very much more when, as already said, we look on 
flexion as the normal position of the infant ; but it must be remembered that 
this effect is largely due to the great head which bends forward on the spine, 
and that the above statement as applied to the spine after the head has been 
removed is more remarkable than appears at first sight. Lateral motion 
is very free, though it is not quite unmixed with torsion. The atlas can 
without effort be brought to the level of the sacrum either to the left or to 
the right. The bending is pretty regular through the different regions. In 
torsion, the sacrum being fixed, the spine could be tsvisted so that the atlas 
looked backward, and could even, with some straining, be carried through 
more than half a circle. From rather crude measurements it appeared that, 
under the above conditions, the rotation in the cervical region was through 
an arc of 45°, in the dorsal region 90°, and in the lumbar region 45°. 
Experiments were then made on the intact body of a girl thirteen years old. 
The head could easily be made to touch the heels, and it could be bent so as 
to fit into the middle of the back. Forward flexion appeared little greater 
than that of the adult, which is to be accounted for by the space taken by 
the head. When the pelvis was fixed, the head could be rotated through 
about three-quarters of a circle. The spine, thorax, and pelvis A\ere next 
made into a ligamentous preparation, and the spine could then be bent back- 
ward until the atlas was almost within an inch of the pelvis. (It is to be 



30 PEDIATRICS. 

remembered that, unlike the last preparation, the sternum in this case was 
still in place.) 

Under these conditions the spine could be flexed so as to make the atlas 
touch the upper end of the sternum and the pelvis the lower. Lateral 
motion was easy until it reached such a degree that the ribs on the flexed 
side came in contact. When the pelvis was fixed, the spine could easily be 
rotated through an arc of 90° without the action of the atlas. 

Professor Dwight has pointed out the rather remarkable fact that at 
all ages, from birth upward, the spine of the fourth lumbar vertebra is (as 
in the adult) on a level with the highest point of the crest of the ilium. 
Under certain circumstances this might advantageously be used as a starting- 
point from which to count. At birth the spinal cord descends only the space 
of about one vertebra lower than in the adult. The third lumbar spine, 
which should mark its termination, cannot be easily recognized under three 
years, but the correspondence of the top of the ilium with the fourth ver- 
tebral spine allows its position to be estimated. It might be desirable to 
know how far the cavity of the spinal dura mater descends inside the 
sacrum. Recent investigations by Dr. R. Wagner show that in children 
under a year old it ends usually near the top of the third sacral vertebra, 
which makes it a little lower than its usual termination in the adult. The 
point on the surface corresponding to this could be approximately esti- 
mated without any definite landmarks. 

NECK. — Now notice the large heads and short necks of these infants 
(Cases 3 and 4, facing page 26). 

It is customary to say that young babies have no necks ; and yet when 
speaking of the spine I stated that the cervical region of the vertebral 
column of the infant and young child is relatively longer than in the adult. 
From this point of view the shortness of the infant's neck must be seeming 
rather than real, but from a clinical stand-point it is real enough. The 
causes of the short neck are first the large head, which naturally falls for- 
ward, covering the upper portion, and next the high position of the sternum 
encroaching on it from below. The large proportion of subcutaneous fat 
tends to make the neck appear still shorter. 

Symington, referring to the soft parts, says, " The peculiarity of this 
part of the child's neck is not that it is relatively short, but that it is higher 
in relation to the vertical column than in the adult." He has shown by a 
series of observations that the larynx is at first placed much higher than 
later. In the adult the lower border of the cricoid is about on a level with 
the top of the seventh vertebra. In the infant it usually seems to be near 
the lower border of the fourth vertebra. 

HEAD. — As a rule, if you take the measurements of the head over the 
middle of the forehead and around to the occipital protuberance, you will 
find that at birth the circumference is about 33 cm. (13 inches). 

FoNTANELLES. — The Opening between the frontal bones and the ante- 
rior borders of the parietal bones is called the anterior fontanelle, and, though 



THE INFANT AT TERM. 



31 



somewhat depressed below the level of the bones at first^ should soon be 
about on a level with them. Its size is variable, but is usually about 1 to 2 
cm. (J to I inch) long, and about 1 cm. (^ inch) wide. In the early days and 
even weeks of infancy the frontal suture is usually open in its upper part. 
The anterior fontanelle at term is well represented in this skeleton of the 
infant at term. (Lecture IV., Fig. 33, page 118.) 

The opening between the occipital bone and the posterior edges of the 
parietal bones is much smaller, is of less significance than the anterior open- 
ing, is often temporarily obliterated by the overlapping of the bones, and is 
called the posterior fontanelle. You see it here beautifully shown in the 
skull of a new-born infant. 

Fig. 4. 




Skull of Infant at term, natural size. Posterior view, showing parietal and occipital bones and posterior 
fontanelle. Warren Museum, Harvard University, 

Face and Cranium. — You will notice that the proportion of the face 
to the cranium in these infants (Cases 3 and 4, facing page 26) is strikingly 
different from what we meet in adults, where it is as one to two, while 
according to Froriep the face in the infant is to the skull as one to eight. 

If we contrast the front view of the face and cranium of the infant and 
of the adult by counting as face all below a line at the tops of the orbital 
arches, and as skull all that is seen above that line, considering it projected 
on a vertical plane as in a photograph, we find that in the infant the skuU 
forms about one-half, and in the adult much less. 



32 PEDIATRICS. 

It is found that the height of the orbit bears pretty nearly the same pro- 
portion to the skull at all ages, but that it equals barely a third of the adult 
face, while it makes nearly a half of it at birth. While the top of the nasal 
opening retains pretty nearly the same relation to the orbit at all ages, its 
lower border is but very little below the lowest point of the orbit at birth, 
while it is much below it in the adult. In the latter, a line connecting the 
lowest points of the malar bones crosses the nasal cavity, or at least touches 
its lower border, while in the infant it runs almost half-way between the 
lower border and the edge of the alveolar process. The breadth of the skull 
in its greatest diameter in the infant equals, or even exceeds, the total height 
of the skull and the face, while in the adult it is but about three-quarters of 
it. Still more striking is the difference between the length and the breadth 
of the face at different stages. The breadth, measured between the most dis- 
tant points of the zygomata, is to the height of the face in the adult about as 
nine to eight, while at birth it is perhaps as much as ten to four. 

The side view is equally or even more characteristic. The auditory 
meatus is situated about midway between the front and the back in the 
infant, but in the adult it is decidedly behind the middle. The face appears 
to be but an insignificant part of the whole structure. 

Ja"ws. — The lower jaw is almost on the same plane as the mastoid 
process of the temporal bone, and the upper border of the zygoma is about 
on a level with the floor of the nasal cavity, while in the adult it is at or 
near the level of the floor of the orbit. It is evident that a very important 
factor in the adult face is the development of the jaws and of the teeth, and 
that it is due to their rudimentary condition that the face is so small in 
infancy. The difference in the comparative development of the lower jaw 
at birth and at three years is well exemplified by these two skulls (Division 
II., Lecture III., Fig. 16, page 67). 

Gums. — The gums do not meet in the new-born (McClellan). They are 
composed of a dense fibrous tissue covered by vascular mucous membrane 
of very slight sensibility, and are protective to the growing teeth. 

All these points you will find of practical importance when you are 
asked to determine whether the face and skull at various ages are normal, 
or present some vice of formation. 

Young infants frequently have at birth quite a startling shape to their 
heads, produced by pressure. One side of the skull may be flattened while 
the other bulges, or the natural diameters of the head may be altered, pre- 
senting a long narrow head instead of the round, well-formed cranium. 
These different shapes give at times an idiotic expression to the infant w^hich 
causes much distress to the parents. In almost every case in my experi- 
ence these abnormal appearances pass away as the skull and brain grow, 
and do not, as a rule, indicate disease unless very extreme, so that it is well 
to state this fact to the parents at once and thus to relieve their minds. 

Naso-pharynx. — A knowledge of the change in size and shape of the 
nasal cavities and naso-pharynx in the course of growth is very important. 



THE INFANT AT TERM. 



33 



Valuable work has been done by Professor Disse on this subject. He 
divides the nasal cavity into the vestibule in front, the exit behind, and the 
intermediate portion, which consists of an upper olfactory region, occupying 
the ethmoidal portion of the cavity, and a lower respiratory region, occupy- 
ing the maxillary part. In the infant the nasal cavity is relatively long 
and shallow, and the respiratory portion is very narrow. 

These casts in fusible metal taken from the Warren Museum of the 
Harvard Medical School were made by Dr. S. J. Mixter, and, as you see, 
show a striking difference between the infant and the adult in the propor- 
tions of the inferior meatus. 

Fig. 5. 




I M marks inferior meatus ; I T marks inferior turbinate bone ; A marks antrum. 
Warren Museum, Harvard University. 



Observe that in the adult preparation the metal runs deep under the 
inferior turbinate bone in the form of a long cylinder, while in the infant, 
though the inferior turbinate projects slightly into the nasal cavity, there is 
but a very minute expansion below it, and none passing up behind it. 



34 PEDIATRICS. 

According to Professor Dwight, the height of the posterior nares at birth 
is 6 to 7 mm., and the breadth between the pterygoid processes at the hard 
palate is 9 mm. 

In infancy, the posterior border of the vomer is very oblique. Situated 
just behind the nasal cavity is the upper or nasal portion of the pharynx, 
which shares in its changes. I may perhaps be permitted to doubt whether 
many practitioners who have not had the advantage of modern anatomical 
teaching appreciate how small a cavity the naso-pharynx is even in the adult. 
Its height is twenty millimetres, and its antero-posterior diameter, from the 
hard palate back, is twenty to twenty-two millimetres. In the infant it is 
very much smaller. It is less of a vestibule and more of a narrow passage 
running obliquely backward and downward from the constricted opening 
of the posterior nares. The soft palate of the child seems to be placed 
more horizontally than in the adult, and bounds its anterior portion below. 
Kostanecki gives the height at birth as ten millimetres, and its antero- 
posterior diameter as fourteen or fifteen millimetres. 

I do not give you Professor D wight's observations on this point, as it 
seems to me that its shape is so peculiar that measurements are deceptive, or 
at least inadequate to give the proper idea. Imagine the posterior nares (not 
the inferior meatus alone, but the whole opening on either side) large enough 
to admit the end of a medium-sized male catheter, and that this leads into 
the passage just mentioned, and you can conceive how a congestion of the 
nasal mucous membrane in infancy, with the addition of the mucous secre- 
tion, may effectually close the opening from the nose to the pharynx. 

It is, perhaps, not sufficiently recognized clinically how important a 
function is performed by the nasal passages in early infancy, — far more 
important, indeed, than at any other age. I can, in fact, say that the age 
of the infant is in inverse ratio to the dangers which may arise from ob- 
struction of the nares. 

These dangers, consequent on obstruction, congestion, and the resulting 
mechanical disturbance of neighboring parts, thus leading to actual disease 
of those parts, become in the new-born infant of most serious and even vital 
import. 

In my own practice I have seen an infant die of simple acute nasal 
catarrh in the first two or three days of life. In this case the infant was, 
indeed, puny and ill cared for. Nothing abnormal could be detected in the 
throat, or, in fact, anywhere, except in the nares, Avhich were completely 
occluded by the congestion and tumefaction resulting from an acute inflam- 
mation of the nasal mucous membrane. Occurring, as the case did, in the 
earlier years of my practice, I did not appreciate as I do now the extreme 
importance of the naso-pharyngeal function of the young subject. There- 
fore, after prescribing the usual remedies for such cases, on the second day 
of the infant's life, I was surprised to learn that it had died suddenly on 
the third day. 

This unfortunate experience, however, served to draw my attention to 



THE INFANT AT TERM. 35 

the j)roper treatment of this class of cases, and there is no doubt that, with 
due appreciation of the vahie of the nasal function and the danger of 
allowing it to be interfered with, we can, as a rule, even in extremely weak 
infants, prevent a fatal result. 

I speak of this case in connection with the anatomical conditions of the 
naso-pharynx in order that you should appreciate the fact that these details, 
which are somewhat difficult to remember, are not merely of theoretical 
interest, but have a practical bearing on disease. I shall also refer to this 
case and its proper treatment in a later lecture when we are considering 
diseases of the throat and nose. 

Lymph- Vessels of the Pharynx. — An anatomical condition of great 
importance, which I shall especially dwell on when I speak of pharyngeal 
diphtheria, is that in comparison with the faucial tonsils, which are relatively 
poor in absorbents, we find an exceedingly rich plexus of absorbents in the 
posterior wall of the naso-pharynx. 

Eustachian Tubes. — The Eustachian tube in its clinical aspect is so 
closely associated with the naso-pharynx that it can best be spoken of in 
connection with it. In the foetus the nasal opening is below the level of the 
hard palate, which it reaches at birth. While in the adult the cartilaginous 
portion slants downward, nevertheless the opening of the tube is opposite a 
higher part of the nose than in the child. At bu*th the tube is horizontal 
or nearly so. 

Professor Dwight has shown me the opening of the Eustachian tube at 
birth just above the level of the hard palate, and, in a child a year or more 
old, a little below the line of the palate. This statement may perhaps be 
misleading. It must be borne in mind that even if the opening of the 
tube be below the level of the hard palate, the soft palate none the less runs 
beneath it, shutting it oif from the cavity of the mouth and the passage 
from it to the fauces. 

In the infant and the young child there is but a slight development of 
the end of the cartilage which makes in the adult so prominent a fold at the 
back of the pharyngeal opening of the tube, and by its prominence does 
much to determine the depth of the fossa of Eosenmiiller, the recess behind 
it at the lateral posterior angles of the pharynx. At birth this prominence 
hardly exists. The opening of the tube is at first very small. That the 
catheterization of the tube at this age presents great difficulties of its own, 
apart from the intractability of the patient, is sufficiently obvious. 

The tube in infancy, w^hile of course shorter than in the adult, is stated 
to be not only relatively, but absolutely, wider at its narrowest point, which 
may explain the ease with which catarrhal processes travel at that age to the 
middle ear. 

Faucial Tonsils — Pharyngeal Tonsil — Lymphoid Tissue. — The 
faucial tonsils, the pharyngeal tonsil, the lymphoid masses under the mucous 
membrane of the posterior third of the tongue, the lymphoid tissue about 
the orifices of the Eustachian tubes, to say nothing of irregular aggregations 



36 PEDIATRICS. 

of the same tissue in the neighborhood, form a lymphoid ring around 
the pharynx which is most important. It is to be noticed that the passage 
from the nose, as well as that from the mouth, is guarded by this appa- 
ratus. That its function is in part protective seems very probable, in spite 
of the fact that when hypertrophied it gives rise to serious trouble. Be- 
fore birth this system is but slightly developed. Indeed, the follicles at 
the back of the tongue are not alwaj^s to be found at that time. I regret that 
Professor Dwight has not had material enough to aid me in adding much 
to the little that is known as to the progressive development of the tonsils. 
Killian states that the pharyngeal tonsil is at birth a raised bunch containing 
adenoid tissue with ridges running in various directions, often more or less 
converging to a point, and rarely running directly forward and backward. 

A pocket in the pharyngeal tonsil is the famous bursa 'pharyngea. It is 
clinically important merely as a recess in which inflammation may linger 
and secretions be retained. 

As for the physiology of the tonsils, in which I include all the adenoid 
tissue of this region, I will mention that Stohr showed that leucocytes make 
their way from them through the mucous membrane to escape into the 
throat. This process begins with life. He found the infiltration of the 
surface of the tonsil of a child of three months much greater than in the 
case of new-born infants. 

The supposition that this system is protective receives support from 
Killian's observation that the pharyngeal tonsil is much developed in mam- 
mals that live in the dust of houses. Metschnikoff^s theory, that leucocytes 
devour bacteria, does not seem to be supported : nevertheless, it is not im- 
possible that this lymphatic ring forms a bulwark against septic invasion. 

Stohr's observations of the escape of white corpuscles do not necessarily 
conflict with the view that the tonsils absorb the secretions of the parts 
in front. If these secretions are irritating, inflammation of the tonsils may 
result. The effects of enlargement of the faucial tonsils are well known ; 
those of hypertrophy of the pharyngeal tonsil have been recognized only 
within a few years. Indeed, I imagine that it has not been more than ten 
or twelve years since the general practitioner became aware of the existence 
of such a structure. The small size of the naso-pharynx in the infant and 
the young child must not be forgotten, for it explains its obliteration by the 
enlargement of the pharyngeal tonsil. 

Mouth. — I wish you now to get a general idea of the mouths of these 
young infants as I open them for your inspection. You see the whitish, 
comparatively dry tongue, which, with the lips, cheeks, and roof of the 
mouth, immediately closes around the inserted finger and produces the sen- 
sation of sucking. The mouth, then, as a whole, is pre-eminently an organ 
intended for the reception of a liquid food, its mechanism being that of suc- 
tion. It is a natural and necessary passage-way to the organs of digestion, 
but is not at first, as I shall explain to you later, intended to aid the diges- 
tion by a salivary secretion. 



THE INFANT AT TERM. 37 

Gums. — The gums have already been described on page 32. 

Teeth. — At birth there are twenty embryo teeth, ten in each ja'w, envel- 
oped in their respective tooth-sacs, protected above by the submucous tissue 
and mucous membrane, on either side by alveolar bone-substance, and below 
by the groove in the maxillary bone from which the alveoli have developed. 

I do not propose to undertake a general description of the cavity of the 
mouth, but shall merely call attention to some especial points in connection 
with the discussion of the relations of the pharynx. A median section of 
the infant's head show^s very strikingly the want of height of the naso- 
pharynx and the great obliquity (approaching the horizontal) of the pos- 
terior edge of the vomer. The naso-pharynx is relatively very long from 
before backward. Strange as it may seem, the distance from the back of 
the hard palate to the soft parts of the back of the pharynx (excluding the 
tonsil) is about as great at bu'th as in the adult. 

This statement appears incredible, but is easily proved by measurement. 
The tongue of the infant is greatly w^anting in vertical thickness, and is 
shown on such a section to be long and low. The soft palate rests, there- 
fore, on the tongue, and, the mouth being closed, runs in the main backward, 
descending very much less than in the adult. The uvula is rudimentary 
(Merkel). It seems to me that, owing to the depth of the pharynx (from 
before backward), the soft palate is unable to shut off the passage to the 
naso-pharynx as completely in early infancy as subsequently. 

It is very curious that, in spite of these peculiarities, the distance from 
the tip of the uvula to the top of the epiglottis is relatively as slight in the 
infant as later. 

Hard Palate. — I shall now call your attention to the level of the hard 
palate, and to what vertebrae are behind the mouth at different ages. This 
may be studied in connection with the position of the larynx already men- 
tioned. We find by examining anatomical specimens that at bfrth and in 
the early months of life the line of the hard palate, continued backward, 
would strike near the top of the basi-occipital, that is, near its junction with 
the sphenoid, or perhaps even strike the latter. Accordingly, at this age, 
if the finger be introduced directly backward through the mouth, pushing 
the soft palate upward, it will strike the occipital bone, and, being carried a 
little downward, will pass over the arch of the atlas, the base of the odon- 
toid, and the body proper of the axis. Going still lower, the top of the 
third cervical veretebra might be felt, but the larynx would hardly permit 
the finger to go lower, and the parts are. so small that I doubt if much 
could be recognized below the axis. 

Brain. — The brain of the new-born infant is proportionately very much 
larger than in the adult, bearing a relation of about 15 to 1. (Vierordt.) 

Eye. — The eye is anatomically perfectly developed in the new-born. 
(McClellan.) 

Ear. — The development of the ear, as stated by McClellan, is in its 
several parts very unequal. The structures of the internal ear, the tympanic 



38 PEDIATRICS. 

cavity, and the auditory ossicles are fully formed at birth, while the ex- 
ternal auditory meatus, the Eustachian tube, and the mastoid portion of the 
temporal bone undergo many modifications before their full development at 
puberty. At birth the meatus passes inward and inclines downward, and 
the membrana tympani is almost horizontal, conditions to be remembered as 
necessitating a little different management of the ear speculum from what 
you are taught in the examination of the adult ear. (Vide Lecture III., 
page 65.) 

The mastoid antrum exists at birth, but the cells do not develop until 
later. 

Petro-Squamosal Suture. — An important anatomical condition ex- 
isting at birth is, that the peti^o-squamosal suture is open, allowing a close 
connection between the blood-vessels of the brain and the middle ear, with 
its resulting clinical significance. 

THORAX. — The thorax of the infant forms the upper and smaller end 
of the egg-shaped body which I have already described the trunk as pre- 
senting. As I have pointed out, the small shoulders of the infant make the 
chest very different from that of the adult. Besides this, the whole shape 
of the thorax is very peculiar. The proportion of the dorsal region of the 
spinal column is pretty nearly the same throughout life, but the thorax 
itself varies greatly. At birth the thorax is very insignificant. In front 
the breast-bone is relatively much smaller than that of the adult male, but 
not very different from some very small breast-bones which are occasionally 
met with in women. I shall consider this in detail later, and I now merely 
mention that the lower part is but slightly developed. The borders of the 
ribs diverge relatively rapidly. This is perhaps due to the great breadth 
of the abdomen. 

Top of the Sternum. — The sides of the thorax are not relatively so 
long as in the adult, which is probably partly due to the lesser development 
of the lower ribs and partly to the very important characteristic of the 
infant's thorax, — namely, that the top of the sternum is placed higher than 
in the adult. The top of the sternum in the latter is about on a level with 
the disk between the second and third dorsal vertebrae. The top of the 
sternum, according to Symington, is opposite about the middle of the first 
dorsal vertebra in the new-born infant, and a frozen section by Kiidinger 
shows it to be rather below the middle of the first. 

Diameters. — Another most important peculiarity of the infantile and 
child's thorax is its want of breadth. In the adult throughout the thorax, 
from about the level of the second costal cartilage, or even a little higher, 
to the top of the diaphragm, the antero-posterior diameter of the interior 
of the thorax is to the transverse as one to two and a half or one to three, 
there being, of course, a certain amount of variation. At birth, on the 
other hand, it is as two to three. 

It is well known that in the infant the ribs are more nearly horizontal 
than in adult life. A striking feature of the young infant's chest is that the 



THE INFANT AT TERM. • 39 

ribs form the sides of the chesty and the sternum and cartilages the front. I 
will now give a more detailed description of the latter parts, which are of 
great importance for two reasons : first, on account of their influence on the 
type of respiration, and, secondly, because the costal cartilages are used as 
landmarks for the organs beneath them. 

Ossification. — At birth the sternum is practically a strip of cartilage 
in which a varying number of bone-centres have been deposited. There is 
one for the manubrium and usually one or two for the second and third 
pieces, those for the latter being very frequently double. These, however, 
are mere thickenings of the cartilaginous strip, which is flexible and pliable 
in all directions. The divisions of the sternum in infancy are plainly seen 
in these skeletons, especially in the larger one, which is nineteen months old. 
(Lecture IV., Figs. 33 and 34, page 118.) 

Movement of Ribs. — A word as to the movements of the ribs will 
be of interest before we discuss the mechanism of respiration as a whole. 
The movements of the adult ribs are very imperfectly explained in many 
of the treatises on anatomy, and in others the explanation is labored 
and complicated. A ligamentous preparation of the spine, with a small 
piece of each rib in situ, shows the following state of affairs. The first 
rib moves up and down on a single axis rimning through the head of the 
rib resting against the body of the vertebra and its tubercle on the trans- 
verse process. This movement is a perfectly simple one, the front of the rib 
moving up and down, and no other movement is possible. In the second 
rib the conditions are practically the same ; but in the third there appears a 
new feature, which is more developed farther down. It is that the tubercle 
of the rib no longer remains in place on the transverse process, but slides up 
and down on it, so that while the inner end of the axis remains stationary 
the outer end is raised (in respiration), and consequently we have, in addi- 
tion to the raising of the forward end of the rib, a swinging upward of its 
outward convexity, which may be referred to a rotation on an imaginary 
antero-posterior axis. Skipping now to the last rib, which has no tubercle 
and rests on no transverse process, we find that Ave can raise or depress it, 
move it forward or backward, and circumduct it, by carrying it from one 
of these positions to another. This is true in a less degree of the eleventh 
rib, and perhaps to some extent of the tenth. The raising of the front of 
the ribs not only increases the antero-posterior diameter of the chest, but, by 
bringing the lateral convexity of each rib to a higher level, also increases 
the transverse diameter ; this is further increased by the rotation of the 
longer ribs on an antero-posterior axis. The freedom of the lowest ribs 
allows them to be pulled backward and downward by the muscles of the 
back, thereby giving a firmer attachment to the diaphragm, and thus favor- 
ing its contraction, or they may be drawn inward by it or upward, following 
the outer ribs. It is to be remembered that in such a ligamentous prepara- 
tion the movements are far more extensive than they can be in life, owing to 
the restraint exercised by the sternum and costal cartilages as well as by the 



40 • PEDIATRICS. 

soft parts. The influence of the sternum is especially important, as in the 
adult the body is in one piece, and the amount of motion between it and the 
manubrium is probably not often great. 

Kespiration. — An important feature in the mechanism of thoracic 
respiration is the rigidity of the thorax. In the infant at birth this rigidity 
is almost wholly absent, as it is found only in the ribs. 

The sternum, as has already been said, is at this age practically a per- 
fectly flexible strip of cartilage, for the small points of ossification in it only 
modify the softness of certain separate parts. The dorsal region of the 
spine is not fixed as a concavity, but can be bent freely backward. The 
motions of the ribs are, as Professor Dwight has satisfied me from our ob- 
servations on the dissected spine, practically the same as in the adult, but 
the eflect of these motions is different. In the first place, as has been 
shown, the ribs are more nearly horizontal, and the thorax, even after death, 
is in what is called the inspiratory condition. The nearly horizontal first 
rib can hardly rise any higher unless the whole spine is bent backward. 
The ribs, being straighter than in the adult, do not when raised increase 
the breadth of the chest to the same degree. The nature of the infantile 
respiratory movements is far from easy to analyze. Sometimes it seems 
abdominal and sometimes thoracic. The fact is, that at first it is of a very 
indefinite type. The thorax seems to expand as it can. It is common to 
see its lower part drawn inward by the contraction of the diaphragm. 

An examination of the living subject during the different periods of 
infancy has been made by me with considerable interest, and my results 
coincide closely with what I had already been led to expect from my ana- 
tomical and physiological studies. At birth no especial part of the respira- 
tory apparatus has attained a sufficient development to insure its continuous 
equable action, and I have therefore found, as would be expected, irregular 
respiratory movements and no decided type of respiration. 

A sufficient number of observations, however, have not yet been made 
to warrant our stating any especial age at which the type of respiration in 
the two sexes separates and the female infant assumes the thoracic type of 
respiration. But if the breathing of the infant is essentially irregular in 
type, it is admirably adapted to the wants of its age. The elastic thorax 
can give way under pressure and expand in almost any direction. The 
flexible sternum submits to liberties which no adult breast-bone would 
endure. One-half of the chest may be compressed and yet the other go on 
acting independently. 

The facts concerning the shape of the infant's thorax, which I have 
already pointed out, — namely, that the top of the sternum is higher, 
reckoning from the spine, that the ribs are more nearly horizontal, and that 
. (probably) the lower part of the sternum is relatively less developed than in 
the adult, — necessarily imply certain peculiarities in the relations of the 
internal parts. There is, however, a difficulty in understanding and stating 
these peculiarities, which, though sufficiently evident, is often overlooked, 



THE INFANT AT TERM. 41 

and which may occasion both obscurity and confusion. This is the want 
of a generally accepted standard by which to judge of the position of these 
parts. Is this standard to be the spine or the front of the chest ? We can- 
not use both indiscriminately, for their relations differ with the age. It is 
clear that the spine is the more fixed point of the two, and therefore the 
better scientifically ; but for most clinical purposes it is desirable to refer 
to the front of the body. 

Diaphragm. — I shall now speak of the position of the diaphragm. 
This, as is well known, rises highest on the right over the summit of the 
liver, is a little lower on the left, and lower still at its tendinous centre in 
the median line. It is generally stated that the diaphragm is higher in the 
child than in the adult. Dwight's observations, partly original, partly on 
the frozen sections of other writers, give the following result. In the 
infant the diaphragm appears to be opposite the disk between the eighth 
and ninth dorsal vertebrae. 

We now come to the insertion of the front of the diaphragm. In the 
infant it appears as if there were a lower insertion of the diaphragm to the 
sternum and the seventh costal cartilages than in the adult. Usually the 
line runs from one costal arch to the other, somewhat above the apex of the 
ensiform cartilage, leaving, therefore, a space on either side of the latter, 
where the interior of the thorax is against the abdominal walls. It is re- 
markable how vague and various are the statements in anatomies on this 
point in the adult. The sternal origin of the diaphragm is said in some 
instances to arise from the ensiform near its base, and in others near its 
apex. Undoubtedly there is ground for both assertions. In the two well- 
known median frozen sections of the body by Braune, it arises in the male 
at the apex of the ensiform, and in the female near its base. I hesitate, 
therefore, to assert that there is any difference in the points of attachment in 
the infant, but the effect is different none the less. Owing, perhaps, to the 
greater flexibility of the body and to the less firm attachment of the internal 
parts one to another, it certainly seems that at least after death the thoracic 
cavity is more accessible at the sides of the ensiform than it is in the adult. 

In the adult it may be as low as the middle of the tenth vertebra, but 
more often probably will be at the disk above it or the lower part of the 
ninth vertebra and occasionally higher. In Rtidinger's median section of a 
woman in the last months of pregnancy, it is as high as the lower border of 
the eighth. We may conclude that, while there is some variation, on the 
whole, the central point of the diaphragm is in the infant higher in relation 
to the spine than later in life, and that it gradually becomes lower. How 
high the diaphragm rises laterally is hard to say, for it is a point very diffi- 
cult to observe. According to Kolliker, in the foetus at term, on the right, 
it reaches the level of the anterior end of the fourth cartilage, and on the 
left that of the fourth intercostal space. Henke adds to this quotation that 
certainly after respiration has begun it will never be so high again. 

There is another point concerning the attachment of the diaphragm to 



42 



PEDIATRICS. 




Fig. 



F.O. 



^ 



the front of the chest which will most conveniently be considered a little 
later : so, keeping this in reserve, I shall pass on to a consideration of the 
thoracic organs. 

Thymus Gland. — The thymus gland exists at birth, and lies above and 
to some extent before the heart. It will be referred to later in the lecture 
on Development. (Fig. 18, page 73.) 

Heart. — The most striking peculiarity of the infant's heart is that it is 
less covered by the lungs than in adult life. Together with the thymus 
gland it forms a solid mass from the posterior mediastinum to the sternum, 
pushing the lungs far apart. It is to be noticed, however, that the pleural 
cavities extend as far forward as in the adult. The relations of the heart 
to the chest-walls are curious in the infant, for these anterior walls are, as 
already stated, high in relation to the spine, yet the heart itself is high in 
relation to the walls. At least the upper half of it is so. With regard to 
the apex and the lower borders the relations are less certain. We usually 

find the impulse of 
the heart rather higher 
and nearer to the mam- 
mary line in the infant 
than in the adult. The 
weight of the heart at 
birth is 20.6 grammes 
(about f ounce), ac- 
cording to Boyd, and 
its proportion to the 
rest of the body is 
largest at about the 
time of birth. 

It will be well for 
you in this connec- 
tion to examine again 
carefully this heart 
of the new-born in- 
fant which I have 
already shown you. 
(Lecture I., Fig. 1, 
page 21.) As the" 
foramen ovale is so 
often open at birth, I 
should also like you to 
familiarize yourselves 
with what a patent 
foramen ovale looks like, as seen in this specimen (Fig. 6) of an older 
infant's heart, where you see there is a free and permanent connection 
between the right and left auricles. The heart is slightly hypertrophied. 




/ 



I 




Right auricle and ventricle. Infant's heart. Open foramen ovale, 
marked F.O. Warren Museum, Harvard University. 



Fig. 7. 

















^^^.-■A 









v,* 



/7 






Section of foetal lung at 5 months, showing development of bronchi ; no alveoli. 







?■%-»: 



T~^'f 



Section of infant's lung at 10 months, showing increased proportionate amount of parenchyma 
in comparison with the foetal condition ; distended alveoli. 



THE INFANT AT TERM. 43 

Common Carotid Artery. — The common carotid artery lias in the new- 
born half the length of the descending aorta, but this proportion is much less- 
ened at a more advanced age, when the vertebral column increases in length. 

Veins. — According to Jacobi, there are one hundred valves in the veins 
of the lower extremities of the new-born. 

Pulmonary Artery. — The pulmonary artery also, as stated by Jacobi, 
is from two to four centimetres (three-fourths to one and five-eighths inches) 
larger than the descending aorta. 

Lung. — I have already referred to the fact that the liver encroaches so 
much upon the space which on the right side of the thorax is occupied later 
by the lung that an important diiference is found between the percussion of 
the right and the left lung. On the right side the eleventh rib behind marks 
the lower border of the lung, while it descends as low as the twelfth rib on 
the left side. In front the lung extends to about the fourth or fifth rib on 
the right side and the sixth rib on the left side. The lung at birth is char- 
acterized by its embryonic type. The infant's lung represents an interme- 
diate condition of growth, which illustrates the gradual change from the foetal 
to the adult condition. These photo-micrographs (Figs. 7, 8), made by Nor- 
thrup, of sections of a foetal lung at five months and of an infant's lung at ten 
months, explain fairly well the anatomical conditions of the lung at birth. 

These conditions have been careftiUy studied by Northrup, who deserves 
great credit for the work which he has done on this subject, and which will 
be referred to later in the lecture on Development, and also in that on the 
Lungs. This author in speaking of the characteristics of the lung in infan- 
tile life says that if we examine the lung of a five mouths' foetus it is found 
that the bronchi constitute the entire respiratory tract thus far developed. 
At the terminal end of the bronchi there are bud-like dilatations, which are 
the rudimentary air-spaces. Between these dilatations, and separating them 
from each other, is loose, delicate connective tissue, which makes up the 
remaining bulk of the lung, so that Avhat subsequently becomes the alveoli 
is about equal in extent to the previous bronchial development. This 
rudimentary air-space is destined to enlarge, subdivide, and finally, in early 
adult life, to occupy all the available room among the bronchial branches. 
The loose connective tissue becomes finally thin, dense bands constituting 
the stroma. This serves to distribute the vascular net-work, and upon this 
are laid the close-fitting epithelial linings of the air-spaces. In foetal life 
the mucous membrane lining the bronchial tubes is loosely attached to the 
muscular walls, and is commonly seen lying in wavy folds within the con- 
tractile ring, where the same delicate connective tissue loosely holds the 
growing tissues together. As has been said, the aerating portions of the 
lungs develop as bud-like dilatations at the tips of the smallest bronchi. 
These dilatations in the course of their development extend into the stroma. 
The epithelium, changing from the columnar type characteristic of the smaller 
bronchi, covers the newly-made walls with flat respiratory epithelium. At 
birth the loose connective-tissue stroma of the foetal luno; of five months has 



44 PEDIATRICS. 

been condensed into rather thick alveolar walls. Another feature of tlie 
child^s lungs as contrasted with those of adults is the behavior of the blood- 
vessels. Being loosely restrained in the walls, they easily become distended 
and tortuous and encroach upon the cavity of the alveoli. With small 
alveoli, thick walls, and abundant distribution of vessels, it is easy to under- 
stand how, in hypostasis, distention of the vessels may be an important factor 
in displacing the air in feeble subjects with weakened respiratory vigor and 
partially obstructed bronchi. Finally, the lung of the infant diifers from 
that of the adult mainly in the following respects. Proportionately the 
extent of the bronchial tubes is greater than that of the air-spaces. The 
connective-tissue stroma is likewise in greater abundance and tends to cellu- 
lar proliferation. The submucous connective tissue of the bronchi is loose 
and more abundantly supplied with nuclei, and its vessels are held more 
loosely. The cells lining the air-spaces form a continuous layer. The 
alveoli are small, their epithelium proliferates abundantly, and the absorb- 
ents accomplish their work slowly, the blood-vessels playing a more im- 
portant role. These facts are to be borne in mind in connection with the 
bronchial lesion which forms so important a part of broncho-pneumonia. 

ABDOMEN. — The essential differences between the abdomen of the 
infant and that of the adult are, first, the great size of the liver in the former. 

Liver. — This organ, especially on the right side of the abdomen, en- 
croaches on the space which is later occupied by other organs. Its relative 
weight to that of the whole body at birth is about 1 to 18. (McClellan.) 

Kidney. — Second, but of less importance, is the relatively large size of 
the kidney and the supra-renal capsules. On the left side of the abdomen 
these conditions are not of much importance, but on the right, occurring as 
they do in connection with the great size of the liver, the large kidney occu- 
pies a lower position, and thus still further curtails the free space in the 
right flank. Viewed from the stand-point of the adult condition the rela- 
tions are, as has been pointed out by Henke, 
much more peculiar on the right than on 
the left. The kidney as a w^hole is lobu- 
lated, as you see in this specimen taken 
from an infant three days old. (Fig. 9.) 

Uric Acid Infarction. — At birth a 
prenatal condition, represented by an 

Lobulated kidney, natural size. Infant , . , t -, j ^ 

three days old. SR marks the supra-renal Orange or a light-red colored deposit near 
capsule. Warren Museum, Harvard univer- the pyramids in the Straight tubules of the 

kidney, exists normally. This condition 
is called the uriG acid infarction, and the deposit consists of urate of ammo- 
nium, amorphous urates mixed with uric acid crystals, and some epithelial 
cells. (Plate III., 5, facing page 112.) 

Supra-Renal Capsules. — The supra-renal capsules at birth quite cover 
and surmount the kidneys, as you will notice in this same lobulated kidney. 
(Fig. 9 ; the supra-renal capsule is indicated by S R.) 




THE INFAKT AT TERM. 



45 



Stomach. — Although it has long been known that in the adult stomach 
the greater part of the lesser curvature is vertical, and the long axis of the 
organ more nearly vertical than transverse, yet these facts have been slow in 
getting into the text-books and winning general recognition. It is probable 
that it has so long been taught that the stomach is placed transversely be- 
cause when the abdomen is opened a triangular piece of the stomach comes 
into view, bounded on the left by the costal cartilages, on the right by the 
edge of the liver, and below by a part of its own greater curvature, which 
runs in a gentle curve from left to right. If this alone is seen it is very 
natural to assume that the stomach is placed transversely. The stomach at 
birth is remarkably small, and more tubular than in the adult, the fundus 
being but slightly developed. It is consequently even more vertical than in 
the adult, for it is the enlargement of the greater cul-de-sac that makes the 
obliquity of the axis pronounced. 

This stomach (Fig. 10), taken from an infant three hours old, represents 
very well the organ at birth. Its capacity is 25 c.c. (f ounce). The weight 
of the infant was 2500 grammes (5 J pounds). Although the weight was 
below that of the aver- 
age infant at birth, the ^i«- l^- 
stomach was of about 
the average size, as 
was shown by its gas- 
tric capacity. 

Duodenum. — The 
duodenum, * in the 
adult, has of late 
usually been described 
as ring-shaped, but 
it generally presents 
pretty well marked 
angles, which divide it 
into a horizontal part 
running backward, a 
descending one along 
the right side of the 

spine, a transverse one crossing usually the third lumbar vertebra, and, 
finally, an ascending part along the left of the spinal column, which brings 
the end to about the same level as the beginning. Sometimes the last two 
parts are represented by a single one running obliquely upward to the left, in 
which case the duodenum is called V-shaped. The first horizontal portion 
is often somewhat dilated, and its walls are smooth, the valves beginning 
usually with the descending portion. The walls of the duodenum just 
beyond the pylorus are lined by a continuous layer of Brunner's glands, 
which extends through the first part, becoming more or less broken up 
towards the end. In the infant the shape of the duodenum, as shown 











'^- r. 


.<! ' ;---^- 


1 • ^^Mm. 




i ' il^^K 


t 




^ 



stomach, natural size. Infant three hours old. 
Warren Museum, Harvard University. 



46 



PEDIATRICS. 



by plaster casts, is more nearly that of a ring, the two lower angles being 
rounded off. A constriction is often (perhaps usually) seen at the junction 
of the first and second parts, but Dwight's casts of the infants duodenum 
do not show .the folds, which are very striking in the casts taken from 
adults. That is to say, those of the infant show a few deep cuts into 
the cast instead of a great many near together. I have seen the folds, 



Fig. 11. 



C 







Casts of duodenum taken from infant and adult, natural size. 
Warren Museum, Harvard University. 

however, very richly developed in an infant of three weeks. In one 
case, that of a female six weeks old, Dwight found the duodenum of the 
V-shaped pattern, and, what is more remarkable, after it had passed the 
gall-bladder it was surrounded by peritoneum so as to swing freely as a loop 
suspended from the posterior abdominal wall. As to Brunner's glands, a few 
observations on young children have suggested that they were rather less 
developed relatively than in the adult, but I am by no means sure that this 



THE INFANT AT TERM. 



47 



Fig. 12. 




Normal caecum and appendix, natural 
size. Infant five days old. Warren Mu- 
seum, Harvard University. 



is always the case. The duodenum has been compared to a trap, its ends 
being always higher than its middle, which is thus fitted to retain the fluid 
poured into it from the liver, the pancreas, 
and its own glands, besides that w^hich it 
receives from the stomach. 

The different points concerning the duo- 
denum which I have just described are well 
shown in these casts taken from the adult 
and from the infant (Fig. 11), and must be 
borne in mind when w^e are considering the 
digestive functions of this important part of 
the intestinal tract. 

The number and size of the folds and 
the shape of the duodenum in the adult 
would tend to delay the passage of its con- 
tents through it, and thus it also prevents the 
passage of gases from the small intestine up- 
ward into the stomach. If it be true, as I 
am inclined to think it is, that in the infant 
the system of folds is less developed, its pas- 
sage Avould be relatively easy, which with a 
fluid diet seems desirable. 

C^CUM. — I should now like you to ex- 
amine this specimen taken from an infant five days old. It represents the 
caecum and appendix, and will aid you in understanding an important dis- 
ease which we shall consider later, — appendicitis. 

The caecum is an interesting portion of the intestine at any age, and es- 
pecially in the child. As is well known, the caecum descends in the course 
of development from under the liver in the middle of the abdomen to the 
right iliac fossa, apparently passing first to the right and then descending ; 
thus leaving behind it in its course the right half of the transverse colon 
and the whole of the ascending colon. It is needless to say that if it is 
possible for the caecum to accomplish this journey it cannot be tightly 
bound by the peritoneum. On the contrary, the caecum has a complete 
peritoneal coat and is perfectly free. At birth, and very possibly for a 
year or two afterwards, the caecum has not, as a rule, reached its permanent 
position in the right iliac fossa. I have foimd it to measure three inches 
in length in an infant eleven weeks old. 

Intestines. — From what we know of the development of the intes- 
tinal tract, which was at first merely a loop loosely attached to the posterior 
abdominal wall, it is natural to expect that in the infant and young child 
it should be less fixed than in adult life ; and this is in fact the case. The 
difference is most striking in the large intestine, and is shown particularly 
in the caecum, ascending colon, and sigmoid flexure. That this condition 
gives rise to dangers is evident, and I should say that there is a strong 



48 PEDIATRICS. 

probability that the cases of infantile intussusception which occur with 
unusual frequency during the middle of the first year may arise from 
this anatomical peculiarity, and this makes a thorough knowledge of the 
anatomy of the caecum important. The growth of the different parts of 
the intestine has been studied by Treves. He points out that in adults 
not only does the length of the intestine vary greatly, but also there is no 
constant relation between the small and large intestines. A long small in- 
testine may be followed by a short large intestine, and vice versa, or both parts 
may exceed or fall short of the average. In the foetus at full term the 
length of the intestine, and especially of the colon, is singularly constant. 

Small Intestine. — The average measurement of the small intestine is 
287 cm. (9 feet 5 inches). The greatest variation that I have met with 
amounted to 61 cm. (about 2 feet). 

Large Intestine. — The large intestine at birth, according to Treves, 
measures 56 cm. (about 1 foot 10 inches). So regular are these measure- 
ments that the greatest variation that I have met with in the colon was as 
little as 12.7 cm. (about 5 inches). 

Sigmoid Flexure. — But little of the sigmoid flexure is found in the pelvis 
at birth. 

PELVIS. — The small size of the infant's pelvis is to be noted also as 
the cause which, to a greater or less extent, forces the pelvic organs of later 
life into the abdomen during infancy. This condition is quite evident in 
this spine (Fig. 3, page 27) which I have already shown you. 

BLADDER. — In the infant the bladder is practically wholly an ab- 
dominal organ. (This fact is well illustrated in Division IL, Lecture III., 
Case 18, page 78.) 

UTERUS. — At birth, part of the uterus is above the brim of the pelvis. 

TEMPERATURE. — The temperature at birth is slightly higher than 
in the adult. It is about 37.2° C. (99° F.). 

PULSE. — The pulse varies from 120 to 140 to the minute at birth, and 
it is at times irregular, especially during the first few hours. 

RESPIRATION. — The respiration is about 45 to the minute, but it is 
of a very irregular type, and if you will closely watch the rise and fall of 
the thoracic walls in this infant (Case 3, page 26) you will see that the 
rhythm changes continually. The breathing is superficial, sometimes quick, 
and again dying away so as to be almost imperceptible. This condition, 
if occurring in an older child, would be a symptom of grave disease, but 
may be said to be normal at birth. The rate may be much quicker than 
45, and I have frequently observed it as high as 60 or 70. 

CHART 1. 



A/WA 




Quick Pause Slow Quick 

Respiration at birth for one-fourth minute. Awake, but quiet. 



THE INFANT AT TERM. 49 

HBIGrHT. — The new-born infantas average height is in the male about 
49.5 cm. (19f inches); in the female 48.5 cm. (19J inches). 

WEIG-HT. — The weight of the male infant is usually rather greater 
than that of the female. The average weight in a large number of cases 
showed that of the male to be 3250 grammes (7^ pounds), while that of 
the female is 3150 grammes (7 pounds). Parker, in a careful examination 
of 170 infants at birth, of whom 89 were males and 81 females, found that 
the average weight of the males was 3520 grammes (7f pounds), while that 
of the females was 3290 grammes (7 J pounds). There is, then, as I have 
said when speaking of Case 2, a certain amount of latitude to be accepted 
in this question of weights. The weight, however, has so close a con- 
nection with the vitality of the infant, that although we often see infants of 
light weight vigorous and thriving, and those of considerable weight failing 
to gain, yet as a general index of vitality the weight is a valuable starting- 
point and guide for our treatment. I would impress upon you that all rules 
and averages of this kind are not to be depended upon absolutely, but 
simply represent conditions which with other important factors aid us in 
solving the problem of vitality. 

VITALITY. — In the early hours and days of existence it is the dis- 
turbance of the equilibrium of the infant's vitality which is especially to be 
feared and combated rather than the specific morbid processes of later child- 
hood. We should therefore in each infant carefiilly determine the degree 
-of inanition which we are called upon to deal with at this period of life, 
and I have personally found it useful to divide the weak and strong infants 
into groups according to their weights, allowing, as I have already explained 
to you, a somewhat lighter weight for girls than for boys. 

This table (Table 2) will explain to you the meaning of what I have 

just said : 

TABLE 2. 

Relation of Weight to Vitality. 

<jroups. Weight. Vitality. 

1 2000 grammes (about 4^ pounds) Very low. 

2 . 2500 " " 5J " Low. 

3 3000 " " 6J '^ Fair. 

4 3500 " " 7^ *' Normal. 

5 4000 '< "8 " High. 

6 4500 " "9 " Very high. 

HANDS. — At birth it is quite remarkable to find with what manifest 
strength the infant can grasp your finger. The nails are well formed. 

PBET. — An important part of the infant's anatomy is the foot, and I 
take great pleasure in introducing for your study some original work which 
has been done by Dr. John Dane. 

Here is an infant (Case 5) four days old. Dr. Dane has taken an impression of its 
feet, which shows very beautifully certain points about the instep at birth which are en- 
tirely different from, and in fact controvert, what has heretofore been taught on this subject. 
The practical importance of this truly scientific and laborious work I shall refer to in a 
later lecture. 

4 



50 



PEDIATRICS. 



Dr. Dane speaks of this infant and these impressions as follows : 
" It has been taught that the infant at term is flat-footed. The anatomy 
of the foot at this age allows it to bend up against the tibia from laxity of 




Feet impressions of normal infant four days old. Arch intact. 

the tendo Achillis, and it may seem flat from the stretching of the plantar 
fascia. The fact is that the arch is well formed, with its bones essentially in 
the adult position. Fat infants may, indeed, show the beginning of a pad 

Fig. 14. 




Flat foot impression, infant four days old. Arch broken down. 

of adipose tissue under the arch, which becomes more marked as the infant 
develops, and in this way might easily be thought to be flat-footed.^^ 
These points will be dealt with later in my lecture on Development. 



THE INFANT AT TERM. 51 

Where flat foot really exists, the internal border of the impression shows 
an undulating appearance, and there is evidence of equal pressure over the 
whole of the tracing, as seen in the tracing taken from the foot of this 
infant also four days old. (Case 6.) 

It is interesting and instructive to compare the different appearances 
which are presented in Fig. 13, showing the well-developed arch, and those 
in Fig. 14, representing the true flat foot. 

You should also examine carefully these babies' feet which have pro- 
duced these appearances. 

BONE MARROW. — At birth, and in the early months of life, the 
marrow of the bones is red, as you see in a section of this bone taken from 
an infant seven months old. (Plate 11. , facing page 107.) 

You will notice that the red color caused by the numerous injected blood- 
vessels is more intense at the central portion of the section of this bone than 
at the periphery or towards the ends. I merely show it to you as a normal 
and characteristic condition of early life, and one which may appear again 
at a later period in certain diseased conditions. 

FUNCTIONS. — It is important for you to have a general idea of 
which of the functions are absent, partially developed, or developed at birth. 
The endeavor to call into use an undeveloped function, to tax a partly- 
developed function, or to overtax a developed one, is productive of great 
harm, and it has in my experience been the source of many conditions 
which, looked upon as diseases, are in reality but proofs that our anatomical 
and physiological knowledge has been deficient. 

Voice. — The normal infant at birth should present a developed voice, 
and should cry vigorously, thus assisting the lungs to expand and the new 
circulatory mechanism to be well started. 

Sight. — Although the eye is, as I have already stated, anatomically de- 
veloped and is sensitive to light, and although the visual perception is also 
possibly developed, yet there is still a lack of power to interpret the images 
perceived. 

Hearing. — The auditory sensations appear to be rather dull during the 
first few days of life. This is possibly due to the absence of air from the 
tympanum and a tumid condition of the tympanic mucous membrane. 

Touch. — The sense of touch is well developed. 

Taste. — The sense of taste is well developed. 

Smell. — The sense of smell is probably well developed ; but this is still 
a matter of dispute. 

Sebaceous Glands. — The function of the sebaceous glands is fully de- 
veloped at birth, as I have already described to you (page 23, Case 1). 

Lachrymal Glands. — The secretion of the lachrymal glands is not 
developed at birth. The new-born infant does not shed tears, a fact of some 
clinical consequence in connection with the prognosis as to the convalescence 
of disease in the early days of life. 

Sweat-Glands. — The function of the sweat-glands is not developed at 



52 PEDIATRICS. 

birth as a rule, but according to ray observations perspiration in certain in- 
dividuals certainly occurs at a much earlier period than is usually supposed. 
I have seen an infant, premature at the seventh month, perspire freely one 
week after it was born, and in a number of individuals this function must 
exist in the early days of life. 

Salivary Glands. — The salivary secretion, as has so clearly been 
pointed out by Forchheimer, is not fully established at birth, and conse- 
quently the mucous membrane of the mouth is comparatively dry, and, as 
you see, these infants' tongues (Cases 3 and 4) have a peculiar whitish color. 
This appearance is caused by the epithelium not being washed away by the 
saliva to the extent that it is after the later development of the function of 
the salivary glands. The amylolytic function of the saliva is very slightly 
present at birth, as has been shown by Zweifel and KoroAvnin, who experi- 
mented with infusions of the salivary glands taken from young infants. 
The amylolytic action is indeed so insignificant that it merely shows us that 
the function of the salivary glands in the early months of existence is only 
partially developed and certainly should not be called into use. 

Pancreas. — The amylolytic action of the pancreatic secretion at birth 
is probably not all developed. The fat digestion is fairly developed at birth. 
The albuminoid digestion is fairly developed, but not fully. 

Bile. — According to Foster, " the excretory functions of the liver are 
developed early, and at about the third month of intra-uterine life bile-pig- 
ment and bile-salts find their way into the intestine. A quantity of bile 
secreted during intra-uterine life accumulates in the intestine, especially in 
the rectum, and forms, together with the smaller secretion of the rest of the 
canal and some desquamated epithelium, the meconium. The distinct for- 
mation of bile is an indication that the products of foetal metabolism are no 
longer wholly carried off by the maternal circulation, and that to the excre- 
tory function of the liver are now added those of the skin and kidney." 

BLOOD. — It is impossible by the methods at present known to determine 
exactly the total amount of blood in either infant or adult, but, while the 
adult's blood is approximately about one-thirteenth of the entire weight of 
the body, the infant's is represented by only one-fifteenth. The blood is 
rather more dense than in the adult, and contains a large amount of haemo- 
globin. It is not rich in fibrin, and does not coagulate perfectly, a fact to be 
remembered when we are considering the hemorrhagic disease and haemo- 
philia of the new-born. Soon after birth some of the globules are still 
found to have nuclei, but these soon disappear. 

Red Corpuscles. — The proportion of the red globules at birth is about 
5,900,000 to the cubic centimetre. 

White Corpuscles. — The number of white corpuscles is about three 
times as numerous as in the adult's blood, and about 21,000 to the cubic 
centimetre. 

LYMPHATIC SYSTEM.— The lymphatic system is very active at 
bb-th. 



THE INFANT AT TERM. 53 

URINE. — The amount of urine secreted during the first two days of life 
is very small, and its specific gravity is about 1010. The kidney shows the 
condition of the uric acid infarction, and it is not infrequent to find the 
napkins stained with a uric acid deposit, such as you see represented on this 
napkin (Plate III., 1, facing page 112). 

INTESTINAL DISCHARGES.— Unless a discharge of the contents 
of the intestine has taken place during the delivery, as is so often seen in 
breech presentations, it occurs immediately or very soon after birth, as you 
have already seen in the first case which I presented to your inspection this 
morning. 

Meconium. — This discharge which first comes from the intestine is 
called the meconium. It is inodorous, viscid, slightly acid, and of a brownish- 
black color, such as you see on this napkin taken from an infant a few hours 
old (Plate III., 2, facing page 112). The meconium contains mucus, epithe- 
lium from the intestinal mucous membrane, epidermal cells, hairs, and fat- 
drops from the vernix caseosa which have been swallowed with the amniotic 
fluid from time to time. It also, according to Vierordt, contains the con- 
stituents of the bile, and its total amount is from sixty to ninety grammes 
(two to three ounces), of which the solid part forms about twenty per cent. 
The intestinal contents at birth are sterile. 



DIVISION IL 



NORMAL DEVELOPMENT, 



LECTURK III. 



SPINE.— NECK.— HEAD.— THORAX. 



We have considered in a general and practical way the conditions which 
exist in the infant at term. The data which we have acquired in this con- 
sideration constitute only a part of the alphabet which we are endeavoring 
to master. 

In order to differentiate normal from abnormal conditions in the growing 
infant and child^ we must now examine the different stages of development 
which correspond to the various ages, and thus complete our anatomical and 
physiological alphabet. 

You remember the condition of the cord in Case 2 (Frontispiece), which 
I showed you at the previous lecture. You see that in this infant (Case 7), 

nine days old, the cord 
Case 7. has fallen off. This oc- 

curred twenty-four hours 
ago. 

By a process of dis- 
integration the cord at 
about the seventh or 
eighth day separates from 
the living tissues around 
the umbilicus. A cer- 
tain amount of bleeding 
may take place at the 
point of separation, but 
this is usually very slight : it may, however, be the beginning of one of the 
most serious forms of disease in the new-born, itmbilical hemorrhage. 

You will notice how the umbilical depression is well marked even when 
the infant cries, and you will thus distinguish this normal anatomical con- 
dition following the separation of the cord, from the umbilical prominence 
which I shall show you later as representing cases of umbilical hernia. 
64 



Infant nine days old. 



Natural condition of umbilicus after recent 
separation of cord. 



NORMAL DEVELOPMENT. 55 

SPINE. — The time of consolidation of the bodies of the vertebrae is not 
accurately known, but it may be roughly stated to begin in the third year, 
and, probably, to end in the seventh. A large number of observations must 
still be made before the march of ossification can be determined. The state- 
ments regarding this point are copied from one book to another, and are 
often quite imaginary. 

The union of these chief centres to form the bodies of the vertebrae begins 
in the lumbar region, and is first completed there. This union, however, 
had not taken place in the dorsal and cervical region of the child said to be 
three years old, used for " The Frozen Sections of a Child" (Dwight). On 
the other hand, in a girl of five or six years, figured by Symington, the 
process was found to be hardly finished in the lumbar region, and higher up 
it seemed about the same as in the younger child. 

The process of union of the laminae is probably completed in the first 
few months of life. 

Length. — Aeby gives the following table for the adult spine, showing 
both the absolute and the relative length of the cervical, dorsal, and lumbar 
regions (the measurements are in millimetres) : 

TABLE 3. 

Absolute. 

Cervical. Dorsal. Lumbar. 

Pemale 122.9 + 265.8 + 190.3 = 579 

Male 129.9 + 273.4 + 184.1=587.4 

Relative. 

Cervical. Dorsal. Lumbar. 

Female 21.12 45.7 32.8 

Male 22.1 46.6 31.3 

Cunningham obtained strikingly similar proportions in an average of 
the measurements of six males and five females : 

TABLE 4. 

Relative. 

Cervical. 

Female 21.6 

Male 21.8 

Aeby gives the following table of the average of five infants, and Cun- 
ningham a table of three : 

TABLE 5. 

Relative. 

Cervical. 

Aeby 25.6 

Cunningham 25.1 

The following table shows the results of the measurements of the spines 
of children by various authorities, as well as by Professor Dwight. The 
table requires no elucidation, but I shall call attention to the remarkable 
uniformity of observations by different men in spite of the errors incident 



Dorsal. 


Lumbar. 


45.8 


32.8 


46.5 


31.7 



Dorsal. 


Lumbar. 


47.5 


26.8 


48.5 


26.4 



56 



PEDIATRICS. 



to the personal equation of the measurements and the individual variation 
which doubtless exists. The relative length of the dorsal (more properly 
the thoracic) region throughout the table is somewhat greater than that of 
the adult ; still it appears that after the age of five or six the proportions 
are not far from those of after-life. 



TABLE 6. 

Length of Spine to Sacrum. 



Absolute Length, in Millimetres. 


Relative Length. 
Total = 100. 


Age. 


Observer. 


Cervical. 


Dorsal. 


Lumbar. 


Total. 


Cervical. 


Dorsal. 


Lumbar. 


3 months . . 
6 months . . 
6 months . . 

10 months . . 
2 years, boy . 

2 years, boy . 

3 years, girl . 

4 years, girl . 

5 years, boy . 

5 years, boy . 

6 years, boy . 
9 years, girl . 

11 years, boy . 
13 years, girl . 
16 years, girl . 

16 years, girl . 

17 years, girl . 


Rasenel 
Aeby . 
Aeby . 
Dwight 
Rasenel 

^®^^, • 
Dwight 

Aeby . 

Symingtf 

Rasenel 

Symingtc 

Rasenel 

Aeby . 

Symingtc 

Aeby . 

Aeby . 

Dwight 


m, 
)n. 

m. 


50 

52.5 

53.5 

61 

70 

79.5 

78 

79.9 

80 

80 

80 

85 

91 

95 
100 
107.5 
113 


100 

103 

107 

125 

140 

153.5 

162 

162 

170 

180 

175 

195 

218.7 

220 

221.9 

229.5 

250 


58 

60 

61 

77 

90 

98 
101 
103.3 
104 
135 
106 
150 
153.5 
136 
151 
152.5 
161 


208 

215.5 

221.5 

263 

300 

331 

341 

345.2 

354 

395 

361 

430 

463.2 

451 

472.8 

489.5 

524 


24 

24.3 

24.1 

23.2 

23.3 

24 

22.9 

23.1 

22.5 

20.3 

22.2 

19.8 

19.7 

21.5 

21.1 

21.9 

21.5 


48.1 

47.5 

48.6 

47.5 

46.7 

46.4 

47.5 

46.9 

48 

45.6 

48.5 

45.4 

47.2 

48.7 

46.9 

46.9 

47.7 


27.9 

27.8 

27.5 

29.2 

30 

29.6 

29.6 

29.9 

29.4 

34.2 

29.3 

34.9 

33.1 

29.1 

31.9 

31.1 

30.7 



The figures to the left of the double line in the table express the abso- 
lute length of the different portions of the spine, in millimetres. 

Those to the right are the same figures reduced to terms of 100, within 
a fraction. 

Flexibility. — I have already shown you how very flexible the spine 
is at birth. This flexibility becomes less as the infant grows older. 

In the cadaver of a female child of ten months it was found that exten- 
sion was no longer so free as in the earlier months, and it required a strong 
pull to make the head touch the nates. The dorsal region, however, could 
still be made concave behind. Flexion was free, especially in the lower part 
of the lumbar region, where the pelvis and legs could be swung forward. 
On rotation the head could be turned through an arc of 90° without using 
the joint between the atlas and the axis. In a male child of the same age, 
extension of the spine was found to be still more restricted. 

Curves. — In the last lecture I explained to you that at birth there were 
no natural curves in the infant's spine. 

An important factor in the production of the curves in the cervical 
and dorsal regions is probably the pull of the muscles, as will be presently 
described. The dorsal curve seems to be a permanent condition of a part 
of the general curve of the body. As soon as the muscles of the back of 



NORMAL DEVELOPMENT. 67 

the neck contract so as to raise the head from the chest, the front of the neck 
will be convex, and finally this becomes the habitual position. As Syming- 
ton has pointed out, however, this cervical curve is never, properly speak- 
ing, consolidated, for it can always be obliterated by a change of the posi- 
tion of the head. The production of the lumbar curve is more complicated. 
If an infant be laid on its back on a table, the knees are raised and fall 
apart ; if they are brought together and forcibly pressed down, the lumbar 
region will spring up from the table and the beginning of a lumbar curve 
will appear. It is supposed that this is caused by the shortness of the ilio- 
femoral ligaments, which, when the thighs are brought down, flex the pelvis, 
throwing the promontory of the sacrum forward. As the child begins to 
stand, the body is inclined forward, and when this is straightened by the 
muscles of the back the same thing occurs, for of course it is unimportant 
whether the legs are extended on the trunk or the trunk on the legs. The 
credit of this explanation has generally been given to Ballandin, but it 
appears to belong to Cleland. 

This curve, therefore, is first observed when the child is one or two years 
old, but it is not until some time later that it is habitually present, and I am 
not prepared to say when it actually occurs. It can be obliterated up to adult 
life, and I rather suspect in many cases even later. The influence of the 
muscular system is important not only in forming two of the spinal curves, 
but in maintaining them afterwards. I am convinced that the greater 
rigidity of the body that is found after puberty is largely dependent on the 
muscles. The tonicity of the muscles has a great deal to do with retaining 
the curves of the spine and with limiting its movements. Many of the feats 
of contortionists are due to this power of relaxing antagonistic muscles, and, 
as a rule, we find in children a greater proportion of muscle to tendon than 
in adults. It is, therefore, due more to the want of power to relax the 
muscles than to the lack of a peculiar formation of the bones and joints 
that children cannot perform many of these feats. The importance of the 
muscles in distortions is very great. The spine of the child is flexible in 
many ways, and the unruly pull of a muscle may easily produce a last- 
ing effect. Not only should the muscles have strength enough to maintain 
the figure without conscious effort, but their action should be symmetrical on 
both sides, and should also have a proper relative force before and behind 
(Case 47, Lecture V., page 145). The importance of light gymnastic exer- 
cises is now so generally understood that I need do no more than allude to it. 
What, however, is of great practical clinical interest in connection with the 
anatomical and physiological facts concerning the spine, spoken of above, is 
the way in which they distinctly emphasize the value of this preliminary 
knowledge in the study of preventive medicine. This point will be spoken 
of in a later lectiu^e. 

What I have just told you regarding the curves of the spine at different 
ages will, I think, be better understood and remembered if you will for a 
moment again look at these lines (Diagram 2, Lecture 11. , page 28), repre- 



68 PEDIATRICS. 

senting the curves of the infant's spme at birth and also at different ages up 
to the period of standing. 

These lines were made at my suggestion by Professor Dwight. 

Surface Anatomy. — The surface anatomy of the spine is of much 
importance in the adult^ and must not be overlooked in the child, where it 
presents striking differences. In the first place, a prominent feature in the 
adult, especially in a muscular male, is that a depression is found wherever 
the skeleton shows a prominence, owing to the development of the muscles. 
Thus, the skeleton shows a ridge of spines in the middle line of the back, 
with a valley on either side ; but during life normally we have a median fur- 
row between two swellings formed by muscular masses. In the infant this is 
not the case (except perhaps in the neck), but the back is rounded ; later it is 
more flattened, and the line of the spinous processes, far from being in a 
depression, is rather prominent. This is the more remarkable as when we 
examine the dissected spine from behind we find it very different from that 
of the adult. In the infant the laminae look more directly backward, and 
their presence in the median line is marked by knobs and ridges very 
different from the spine of the adult. Up to a year, or perhaps eighteen 
months, the proportions are not very different, but the spine at three shows 
that a great change has occurred, for the spinal processes now stand out in 
a prominent row, and present very nearly adult proportions. The greatest 
difference is in the dorsal spines, which are relatively broader at their points 
and less gracefully drawn out than in the adult. The bodies of the vertebrae 
still remain less deep, and therefore the relative positions of the spines and 
bodies show less difference than might be expected. For example, the tip 
of the spinous process of the seventh dorsal vertebra in the adult reaches 
down to the lower border of the body of the eighth vertebra, or the head of 
the ninth rib. At three it goes very nearly as far, though its shape is not 
the same. At six or seven the spine has made still further progress towards 
the adult proportions. By the end of the second year the back of the 
living child is not only flatter and broader (the results of continuous 
changes), but there is the appearance of the median furrow, and at five or 
six the differences in this respect from the adult are not marked. It is 
barely possible to count the spines in the infant and young child, and at 
three and four years it is not very easy, though less difficult than in the adult. 

Prominent Spinous Processes. — A source of error is the adjective 
" prominens'^ applied to the seventh cervical vertebra, which naturally sug- 
gests that its spine is the most prominent in the back of the neck. This is 
not usually the case. The first dorsal spine is the most prominent in that 
region. The atlas has no spine at all ; the spinous process of the axis is 
thick and prominent, perhaps relatively less marked in the child than in the 
adult ; the third and fourth spines are very small ; the fifth is not much 
larger ; but the sixth projects more, and the seventh is said to be usually 
the first prominent one. He who trusts, however, to this rule is very liable 
to error, for the relative size of the lower cervical spines varies considerably. 



NORMAL DEVELOPMENT. 59 

The sixth may be the first to assume prominence, and the seventh cervical 
and first dorsal may exceed it but little. It is easier to examine a child of 
three years and upward than an adult, on account of the greater softness 
of the tissues, which allows us to feel more deeply in through the furrow 
of the neck, and, having recognized the axis by alternately flexing and ex- 
tending the head, to count the cervical vertebrse in order. If it should be 
in any case absolutely impossible to feel the third and the fourth, it is better 
to allow a certain space for them and to call the next one the fifth than to 
assume arbitrarily that a certain one is the seventh. Confirmatory evidence 
may be gained from the height of the sternum, to which point I shall return 
later. 

NECK. — I have already referred to the peculiarities of the infant's neck 
at birth. (Lecture II., page 30.) 

Cricoid Cartilage. — Symington states that in two children respect- 
ively five and six years old the lower border of the cricoid cartilage was 
found to be at the lower border of the fifth or at the top of the sixth verte- 
bra. I do not quote his observations at intermediate ages, as the position 
of the head in these measurements varied a good deal. In a girl of thir- 
teen he found that it had reached the adult position ; that is, about on a 
level with the top of the seventh vertebra. 

Epiglottis. — Symington found also that the top of the epiglottis de- 
scends during growth from about the level of the lower border of the atlas 
to the middle of the third cervical vertebra, or even lower. 

Larynx. — This high position of the larynx would imply a greater part 
of the trachea relatively above the sternum, but this is neutralized by the 
high position of the latter. The amount of fat in the neck makes the trachea 
less accessible. The greater distance of the trachea from the surface, as it 
descends, and the greater danger of meeting the large arteries and veins 
above the sternum in the child, are points of anatomy so well known in 
connection with tracheotomy that it seems hardly worth while to insist on 
them. 

Tillaux made a series of measurements of the distances from the sternum 
to the hyoid, the thyroid, and the cricoid, in men, women, and children of 
both sexes. 

Distance from Sternum to Cricoid. — I give a condensation of his 
statements of the distance from the sternum to the cricoid, as the most prac- 
tical. In twelve women it ranged from five and a half to seven and a half 
centimetres, the average being six and a half centimetres. In men the 
variation was greater, ranging from four and a half to eight and a half, 
but the average was precisely the same. Among the men was a boy of fif- 
teen and a half years, in whom the distance was seven and a half centi- 
metres. Tillaux measured thirty-one children, nineteen girls and twelve 
boys, ranging from two years up to ten and a half. There seems no reason 
for keeping the sexes distinct, and I further condense the table by giving the 
average in the cases of several of the same age, with the following result : 



60 PEDIATRICS. 

TABLE 7. 

Relation of Cricoid to Sternum. 
Years. Distance from Cricoid to Sternum. 

21 . . 3.5 centimetres. 

3 4 " 

3^ 4 " 

4 3.8 " 

4| 4 " 

5 .4.5 " 

6 . 4.9 " 

6| 5.5 « 

7 5.1 «' 

7J 4.5 " 

8 5 « 

8^ 5.25 " 

9 5.25 " 

9^ 6.5 " 

10 6.5 " 

10^ 6.5 " 

It seems rather remarkable that at ten years the distance should be as 
great as in the adult, but this may be accounted for by the subsequent 
descent of the larynx, and also, probably, by its proportionate enlargement 
(at least in the male) about puberty. 

The peculiarities of the relations of the top of the larynx and pharynx 
to the spine in the young child are points of much practical importance, to 
which I shall return. The changes which occur during growth depend 
largely on changes in the base of the skull, and on the downward growth 
of the jaws, which will be considered presently. 

HEAD. — Circumference. — The measurement of the circumference of 
the head increases very rapidly, and in early childhood almost attains that 
of the average adult's head. We must therefore be careful about giving an 
opinion that the head is relatively large for the age of the child. I have 
myself measured over one hundred children of different ages in both hospi- 
tal and private practice in order to get a general idea of the circumference 
of the head and its proportion to that of the thorax. The number is, of 
course, too small to make any precise average deductions from, but in a 
general way I have found these measurements useful. 

Circumference relative to Thorax. — Thus, I have found that 
while at birth the head usually has a circumference of 33 cm. (13 inches), 
the thorax, measuring over the nipples and just under the angles of the 
scapulae, has a circumference of 1 or 2 cm. (J to f inch) less. A change in 
these measurements and proportions soon takes place. In the fourth to fifth 
week, for instance, and extending into the seventh and eighth weeks, 38 cm. 
(15 inches) for the head and 35 to 36 cm. (14 to 14 J inches) for the thorax 
I have found to be not uncommon figures. In like manner at five or six 
months 42 to' 45 cm. (16 J to 18 inches) for the head and 41 to 42 cm. (16^ 
to 16 J inches) for the thorax are figures occurring in my measurements. At 
nine months it is not uncommon to find 45.5 cm. (18 inches) for the head 



NORMAL DEVELOPMENT. 61 

and 43 cm. (17 inches) for the thorax. At the end of the first year in a 
number of cases I found that the circumference of the thorax had reached 
and even surpassed that of the head, as seen in this infant (Case S), where 
the head is 45.5 cm. (18 inches) and the thorax 47.5 cm. (18f inches). In 
exceptional cases the thorax surpasses the head at a much earlier period ; 
and I have even seen it to be a trifle larger at birth, but this is unusual. I 
have recently measured a healthy infant whose weight at birth was 3800 
grammes (8 J pounds), whose head measured 34 cm. (13 J inches) and whose 
thorax also measured 34 cm. (13 J inches). In the second year I find very 
varying figures, and the head often still remains larger than the thorax. 
Thus, in these two infants which I shall now show you, one (Case 9), who 
is eighteen months old, has a head measuring 49 cm. (19 J inches) in circum- 
ference, and a thorax 46 cm. (18 J inches), while the other (Case 10), also 
eighteen months old, has a head measuring 47 cm. (18J inches), and a 
thorax 45 cm. (17f inches). Here is another infant (Case 11), t^^enty-one 
months old, who has a head 51 cm. (20 J inches) and a thorax 50 cm. (19f 
inches) in circumference. My measurements have been taken mostly from 
boys. The girls that I have measured seem proportionately for the same 
age to show smaller measurements of the thorax, and to have the thorax 
overtaking in its circumference the head at a rather later date than is the 
case with boys. By the second year the thorax has almost always overtaken 
and surpassed the head. I will now show you some measurements of the 
head and thorax from two to thirteen years which I happen to find in my 
notes. They were all males, and it must be remembered that they are not 
exact averages for a large number of cases, but merely measurements which I 
found corresponded in a number of children of these different ages. I pre- 
sent them as showing especially how it becomes noticeable when the circum- 
ference of the head is taken at random in your general practice, that after 
the second year the measurements of the head correspond pretty closely, and 
depend upon the individual rather than upon the age. The thorax, on the 
contrary, seems to increase year by year. 

TABLE 8. 

Circumferences of Head and Thorax from Two to Thirteen Years. 

Males. 
Years. Head. Thorax. 

2 48 cm. (19 inches) 51 cm. (20^ inches). 

3 51 cm. (20 J inches) 55 cm. (21f inches). 

4 53 cm. (21 inches) 54 cm. (21^ inches). 

5 53 cm. (21 inches) 54 cm. (21f inches). 

6 52 cm. (20^ inches) 55 cm. (21| inches). 

7 54 cm. (21^ inches) 54 cm. (21^ inches). 

8 53 cm. (21 inches) 59 cm. (23^ inches). 

9 54 cm. (21^ inches) 61 cm. (24 inches). 

10 53 cm. (21 inches) 62 cm. (24^ inches). 

11 56 cm. (22^ inches) 63 cm. (24^ inches). 

12 53.5 cm. (21^ inches) 63 cm. (24| inches). 

13 54 cm. (21} inches) 66 cm. (26 inches). 



62 



PEDIATRICS. 



This series of circles, representing the circumferences of the head, thorax, 
and abdomen, will, I think, show you at a glance what you may expect as 
to the relations of these parts of the child in the first year. They represent 
the average of a number of actual cases which I have had an opportunity of 
closely watching in their nurseries from birth to one year. 



Early Weeks. 



Diagram 3 
Months. 
Head. 



Twelve Months. 







Relative circumferences of head, thorax, and abdomen 



The general idea which you can get from these diagrams will, I know, 
help you in your nursery practice, where you have to determine in a few 
minutes whether an infant is fairly developed. No especial significance need 
be given to the circumference of the abdomen in this connection beyond 
what I have previously said concerning the liver, as its measurements, of 



NORMAL DEVELOPMENT. 



63 



course, vary very much normally according to the degree of distention 
present. 

The fact that I have represented the head and thorax equal in the mid- 
dle of the year, and the thorax larger than the head at the end of the year, 
does not establish any rule for these periods, as you see from what I have 
previously said. The diagram merely in a very simple way enunciates 




Infant skull, natural size. Anterior fontanelle 4X3 cm. 
Warren Museum, Harvard University. 

that, although there is great activity shown in the growth of the head, this 
activity is still greater in regard to the thorax. 

FoNTANELLES. — The posterior fontanelle, although ordinarily quite per- 
ceptible at birth, soon disappears, either from overlapping of the bone or 
from a permanent closure, and is usually imperceptible by the sixtli week. 

The anterior fontanelle, so far as my observation is concerned, seems to 
grow larger as the infant grows older, up to about the ninth mouth ; this 



64 PEDIATEICS. 

point is, however, disputed, and the increase may be apparent rather than 
real. It also seems to remain stationary, or almost so, from the ninth to 
the twelfth month, and then decreases slowly. It should be closed by the 
nineteenth to the twentieth month. 

When we study the disease rhachitis you will understand how important 
is a knowledge of the closure of the fontanelles. 

This skull (Fig. 15, page 63) of an infant in the early weeks of life shows 
very well the increase of the diameter of the anterior fontanelle. While, 
as you see, in this skeleton of the infant at term (Fig. 33, page 118) the 
measurements were 3X2 cm. (IJ X i inches), this fontanelle measures 4x3 
cm. (If X IJ inches). 

Face and Ceanium. — As I stated in a previous lecture (Lecture II., 
page 31), the proportion of the face to the cranium in infancy is as 1 to 8. 
Froriep has also made observations on this point in older children, and finds 
the following proportions : 

TABLE 9. 

Proportions of Face to Cranium. 

Age. Face. Cranium. 

Early infancy 1 to 8 

2 years 1 to 6 

5 years 1 to 4 

10 years 1 to 3 

Adult female 1 to 2J 

Adult male 1 to 2 

The small size of the facial portion of the skull in infancy and early 
childhood is well shown in these skulls (Fig. 16, page 67) of the infant at 
birth and at three years, and also in these skeletons (Figs. 33 and 34, page 
118) of the infant at birth and at nineteen months. 

As the child develops, very important changes occur in the base of the 
skull, one of the greatest of which is the downward growth of the face. 
Originally the base of the skull is practically flat. The sudden rise of the 
basilar process in front of the foramen magnum, the angle formed with it 
by the body of the sphenoid, and then the sharp descent of the vomer, are 
adult characteristics of which at birth there is little trace. The nasal cavity 
is shallow and relatively long, the posterior nares are small, and the vomer 
approaches the horizontal. The naso-pharynx has, therefore, very little 
height. The alveolar processes are still undeveloped, and the ramus of the 
lower jaw is very oblique, so that the cavity of the mouth is small. As a 
consequence, the larynx is, as we have seen, placed very high up. One 
of the chief causes of its descent is the downward growth of the face. 

Brain. — Much credit is due to Dr. George McClellan, of Philadelphia, 
for his careful and laborious work, extending over many years, on the 
anatomy of the different periods of life. His careful dissection of the 
infant's brain is very valuable for reference, and I wish to acknowledge the 
use which I have made of it. I desire also to express my appreciation of 
the anatomical work on infants done by Dr. J. W. Ballantyne, of Edinburgh. 



NORMAL DEVELOPMENT. 65 

Dura Mater. — An important anatomical condition in connection with 
the brains of young subjects is that the dura mater is adherent to the skull, 
and thus prevents the collection of extravasations between it and the bone. 

Subarachnoid Space. — The subarachnoid space usually contains a 
larger amount of fluid in childhood than in later life. 

Growth. — I have already mentioned the large proportionate size of the 
brain at birth (Lecture II., page 37). 

Up to the seventh year the brain shows an active growth, and after that 
year increases slowly in weight. The convolutions are not fully developed 
at birth, and are gradually perfected as the child grows older. The various 
centres of the brain which gradually become so highly developed in later 
childhood have but little action, so far as we can judge, at birth and in the 
early weeks. 

Ear. — The osseous meatus is not developed until about the fourth year. 
In introducing the aural speculum under four years of age, you should 
therefore draw the ear forward and downward instead of upward and back- 
ward as in older children and adults, or the canal will be bent on itself. 

Peteo-Squamosal Suture. — The time at which the petro-sqimmosal 
suture closes is not at present known. 

Naso-Pharynx. — Now, if you will again examine these fusible metal 
casts (Fig. 5, page 33), you will see, as I have already pointed out to you, 
in this one taken from an infant, that although the inferior tiu-binate projects 
slightly into the cavity of the nose, yet there is but a very minute expansion 
below it and none passing up behind it. 

According to Disse, it is this part which shows the greatest growth. It 
begins to increase in height directly after birth, and goes on pretty rapidly 
till the beginning of dentition, when it is slow till the second year is com- 
pleted. After the first set of teeth are cut, the groT^i:h is rapid till the end 
of the seventh year. The increase in breadth occurs in the last-mentioned 
period, which also is the time in which the groT\i:h of the olfactory portion 
is most marked. Disse states that the posterior opening doubles its size in 
six months, remains stationary till the end of the second year, and then 
increases again. 

Professor D wight's measurements on bones are as follows : 

TABLE 10. 

Breadth between Ptery- 

Age. Height of Posterior Nares. gold Processes at Hard 

Palate. 

About birth 6 to 7 millimetres. 9 millimetres. 

From 12 to 16 months 13 " 16 " 

" 12 to 18 " 15 " 16 " . 

" 14 to 20 " 14 " 17 " 

" 18 months to 3 years . ... 15 " 21 '• 

" 2 to 4 years 15 " 20 " 

About 6 years 16 " 20 " 

7 or 8 years 20 " 22 " 

About 11 years 18 " 22 " 

17 years, female 22 '« 20 " 

5 



66 PEDIATRICS. 

We may compare with the above, ten measurements which Professor 
Dwight has made on adult skulls. I give both the average and the extremes 
of variation. 

Table 11. 

Breadth between Rery- 
Ten Adults. Height of Posterior Nares. goid Processes at Hard 

Palate. 

Average 28.4 millimetres. 27.7 millimetres. 

Extreme 28 and 31 " • 24 and 31 " 

These figures show that the height does not gain the predominance until 
adult age. At the end of the seventh month the nasal cavity approaches the 
adult shape, though it seems broad in proportion, and has not, of course, 
attained its full size. Merkol has shown that in later adolescence the 
growth of the respiratory portion takes place chiefly in the middle meatus. 
In infancy the posterior border of the vomer is very oblique. With the 
growth downward of the jaw this obliquity is much diminished at the age 
of seven or eight years. 

Eustachian Tubes. — The course of the Eustachian tube and the posi- 
tion of its opening undergo changes corresponding to the development of 
the nasal cavity. As I have already told you, at birth the tube is horizon- 
tal, or nearly so. In the adult the cartilaginous portion slants downward. 
Nevertheless, the opening of the tube is opposite a higher part of the nose 
in the adult than in the child. In the foetus the opening is below the level 
of the hard palate, which it reaches at birth. Up to the ninth month after 
birth, according to Disse, there is but little change. After that time, how- 
ever, the opening is distinctly higher than the floor of the nasal cavities. 
At four years, Kunkel found it to be three or four millimetres higher. In 
the adult it is opposite the end of the inferior turbinate bone. 

Pharyngeal Tonsil. — The pharyngeal tonsil increases after birth, and 
by the end of the first year has a length of eighteen millimetres. 

Professor Dwight tells me that he failed to satisfy himself of the presence 
of anything that could be called a pharyngeal tonsil in the head of an ill- 
nourished child of four weeks which he recently divided in the median line. 
There is probably much variation. Dr. Dwight has a beautiful specimen 
of one in a similar section of the head of a child of three years or less. It 
has a length of about twenty millimetres, and narrows most strikingly the 
passage from the nose to the lower part of the pharynx. 

From the tip of the uvula to the top of the epiglottis Braune found the 
distance to be twelve millimetres in the median section of an adult female. 
In Symington's section of a boy of about six years it is five millimetres. In 
a section of a head of three years or less it is not over two millimetres, and in 
another of four weeks we find that had the mouth been closed when the 
head was frozen, the parts would probably have been in contact. The precise 
progress of the changes from the infantile condition is still to be observed. 
I may say, however, from the sections at the Harvard Medical School, from 
Symington's plates of children of six and thirteen years, and from other 



NORMAL DEVELOPMENT. 



67 



measurements of children, that the change in the first two or three years is 
very great, and that the pharynx of older children resembles more that of the 
adult than that of the infant. Indeed, at four weeks we find the tip of the 
epiglottis on a level with the lower part of the odontoid process, but, of course, 
by opening the mouth and depressing the soft parts space may be gained. 

Hard Palate. — In a child of three years or less the line of the hard 
palate strikes about the middle of the basi-occipital bone. It would hardly 
be possible, without passing the finger round the soft palate, to feel much 
higher than the arch of the atlas. The base of the odontoid process would 
be under the mucous membrane seen at the back of the throat through the 
open mouth. The tip of the epiglottis is at the junction of the odontoid with 
the body of the axis. I doubt if more than the very top of the third verte- 
bra could be satisfactorily explored. At six and at thirteen (Symington's 
plates) I find that the line of the hard palate has about the adult direction, 
— that is, it strikes about the top of the atlas or the basilar process near its 
beginning. In both the finger could probably examine the vertebrae from 
the first to the fourth in- 
clusive. The atlas, how- Fig- 16. 

ever, would be reached 
Avith much more difficulty 
in the older than in the 
younger subject, as the 
relations of the soft palate 
are more nearly those of 
the adult. 

Mouth. — As the in- 
fant grows older the mouth 
becomes an organ more 
adapted for certain uses 
beyond that of a mere 
means of entry for the 
food to the stomach. 

Maxillary Bones. 
— The ossification of the 
maxillary bones begins 
early, progresses slowly, 
and, together with the 
final formation of the jaw, 
is completed at puberty. 
These skulls (Fig. 16), 
one of an infant born at 
term, the other of a child 

three years old, represent the characteristic incomplete development of the 
ramus of the inferior maxillary bone in the early weeks and months of life, 
and its almost complete development at three years. 





Skulls shoAving development of ramus at birth and at three years. 
Warren Museum, Harvard University. 



68 PEDIATRICS. 

The chief characteristic, as you see, is the oblique angle which the ramus 
makes with the body of the bone at birth, and this becomes more evident 
when you compare it with the jaw at three years. You will observe the 
much greater proportion of the ramus to the body of the bone at three years, 
and the nearer approach to a right angle where they join. 

Teeth. — Fleischmann's work on this subject is worthy of especial atten- 
tion, as it will elucidate many points of interest when w^e come to speak 
in a later lecture of diseases of the mouth and difficult dentition. His 
description of the development of the teeth, and McClellan's description, 
which can be found in the first volume of Keating's ^^ Cyclopaedia of 
the Diseases of Children," need hardly be mentioned in detail, but they 
provide us with facts which will in a measure explain certain symptoms 
of clinical interest during the period of dentition. The development of 
the first set of teeth begins at about the seventh week of intra-uterine life, 
and, progressing slowly, is completed about the end of infancy. At birth 
the twenty embryo teeth, ten in each jaw, are so enclosed in the alveolar 
processes that nothing but the smooth mucous membrane is apparent on 
the gums above. Below, they are connected with the branches of the infe- 
rior dental nerve (an important clinical fact to be remembered) through open- 
ings at the bottom of the alveolar processes. When calcification of the neck 
of the tooth begins, elongation also takes place, and, as the tooth is enclosed 
in bony walls below and on the sides, it gradually grows through the point 
of least resistance, namely, the gum, which covers the top of the alveolar 
processes. The continued pressure gradually causes atrophy of the mucous 
membrane, and the crown of the tooth appears on the edge of the gums. 
The various teeth come through the gum at times w^hich are regulated 
according to their development, that is, at times corresponding to the calcifi- 
cation of their roots and consequent elongation. This process usually takes 
place in groups and with considerable regularity in the average normal 
infant. Variations both as to the order in which the teeth appear and in 
the time of their appearance are so common that it seems hardly practi- 
cable to have set rules designating these times. The experience of different 
physicians seems to differ, but all practically are guided by very general 
rules. 

An infant may be born with one or more teeth, as you see in this infant fourteen 

days old, which has just been brought to the clinic to be operated on by Dr. Augustus 

Thorndike, who kindly presents the case for your inspection. You 

Fig. 17. see that it has an everted intermaxillary bone, on the outer side 

i^ of which is the left middle incisor, which evidently came through 

^*^^ the gum before the infant was born. 

Upper incisor tooth in 

infant at birth, natural The first tooth may appear at any time during the 
first year of life, or may be delayed until the second 
year without any other apparent vice of development. In like manner, 
every kind of variation may be met with in the order in which the teeth ap- 
pear, without the slightest evidence of any pathological condition, mental or 



NORMAL DEVELOPMENT. 69 

otherwise, being found either at the time or later. It is therefore unneces- 
sary to alarm the parents by stating that their child is abnormal because it 
has not cut a tooth in the first year. AYe should, however, carefully watch 
these children and be sure that their food contains the proper nutritive 
elements not only for their age, but also for their individual digestion. 

The appearance of the teeth in groups suggests certain practical divis- 
ions which I shall make use of in later lectures to determine various ques- 
tions, such as the best time for ^-eaning, or for vaccination. These divisions 
constitute the dental and interdental periods. In my individual experience, 
the first tooth appears at about the sixth or seventh month, though at times 
I find it much earlier, as at the fourth month, and later, as at the ninth, 
tenth, eleventh, or twelfth month. The first tooth w^hich develops suffi- 
ciently to come through the gum is in most cases one of the middle lower 
incisors. The groups and the dental periods, allowing always for many 
variations, are, as I have noted them, as follows : 

TABLE 12. 

Teynporary Teeth. First Dentition. Twenty in Numler. 
Dental Periods. Groups of Teeth. 

I. 6 to 8 months 2 middle lower incisors. 

II. 8 to 10 months 4 upper incisors. 

III. 12 to 14 months . . . 2 lateral lower incisors and 

4 first molars. 

TV. 18 to 20 months 4 canines. 

V. 28 to 32 months 4 second molars. 

20 

I shall now pick out a number of infants in these various periods who 
happen to have their teeth corresponding to them, and I should like you to 
examine their mouths. Here are five t}^ical cases which will illustrate 
what I have just said. 

Diagram 4. 
Case 12. Case 13. 



Case 14. 








Five periods of development in the first dentition. 



70 PEDIATRICS. 

The second set of teeth begins to replace the first at about the sixth year, 
and this table will aid you in remembering their order : 

TABLE 13. 

Permanent Teeth. Second Dentition. Thirty-two in Number. 
Years. ' Groups. 

6 4 first molars. 

7 4 middle incisors. 

8 4 lateral incisors. 

9 4 first bicuspids. 

10 4 second bicuspids. 

11 4 canines. 

12 4 second molars. 

17 to 25 4 third molars (wisdom teeth). 

32 

The first fiDur teeth of the second dentition are usually called the sixth- 
year molars. They do not replace any of the permanent teeth, but, the jaw 
having grown so as to provide space back of the temporary teeth, they ap- 
pear back of and next to the second molars. This usually occurs at about 
the sixth year. 

In the seventh and eighth years the permanent incisors replace those of 
the temporary set. In the ninth and tenth years the bicuspids replace the 
temporary molars. In the eleventh year the permanent canines replace the 
temporary, and in the twelfth year the four second molars appear. This 
really completes the second dentition of childhood, twenty-eight teeth. The 
remaining four molars belong to a period of adult growth. Diagram 5 
(page 71) shows very clearly the manner in which the permanent teeth replace 
the temporary set between the ages of six and twenty-five years. 

THORAX. — Top of Sternum. — Professor Dwight found on examining 
two children each ten months old that the top of the sternum was in one 
nearly opposite the disk between the first and second dorsal vertebrae, and in 
the other a little lower, near the top of the second. In a black child of three 
years, whose proportions were strikingly infantile for her age, it was near the 
lower border of the first vertebra. In the three-year-old child the subject 
for the work on Dwight's ^' Frozen Sections'^ it was opposite the lower part 
of the second vertebra. In the median section of a boy about six years old 
Symington found the top of the sternum a little below the level of the top of 
the second dorsal vertebra ; he believes, however, that this was an individual 
peculiarity, as in several children of that age he found nearly the adult rela- 
tions. From several observations on the living subject Dwight is inclined 
to agree with this statement. 

Diameters. — The antero-posterior diameter of the interior of the thorax 
is to the transverse diameter at three years, according to Dwight's " Frozen 
Sections," as one to two, and in a child of from five to six (Symington) the 
depth is even relatively greater. The ribs bend much less backward than in 
the adult, and the back, as has been said, first becomes rounder and then 



NORMAL DEVELOPMENT. 



71 



flatter. At four or five years great progress in growth has been made, and 
the infantile form of the thorax has wholly disappeared. Slight changes, 
however, probably go on for some years. 



Diagram 5. 







Eight periods of development in the second dentition. 



Ossification. — Towards the end of the first year the bone-centres of 
the sternum have grown, and the sternum has gained a good deal in stability. 
New points of ossification have probably appeared, but still the sternum is 
essentially cartilaginous, the bone merely consisting of islands in a sea of 
cartilage. At two years of age the manubrium and the second and third 
pieces are nearly ossified, but their shape is made by their cartilaginous bor- 
ders. At three years I have twice seen the manubrium and tlie second 



72 PEDIATRICS. 

piece of the sternum presenting in bone their real shape, while the third 
piece was still framed in cartilage. Sometimes, however, the process of ossi- 
fication is more backward. The ossification of the lower part of the sternum 
is less advanced than the upper part. As to its relative size opinions differ. 
While it seems to me that it is usually small, I must admit that statistics do 
not confirm this view. Probably the individual variation is very great. 
The ribs being comparatively horizontal, the cartilages rise very little, and 
at the lower part of the chest in front they are nearly together, making 
narrow intercostal spaces, the seventh cartilages often meeting below the 
body of the sternum. In the dead body of a young child, especially if 
it be emaciated, it is striking to see how, after the cadaveric rigidity has 
passed away, the sternum and cartilages, forming the front of the chest, 
fall in at the point where they join the ribs. 

Respiration. — At birth there is no decided type of respiration for the 
two sexes, as I have proved by a number of observations. As the infants, 
both male and female, however, grew older and a more equable respiratory 
mechanism became established, I found that, as a rule, in the early months 
of life the type of respiration was abdominal. This infant (Case 17), nine 
months old, presents the irregular respiration of infancy, but you see the 
type is distinctly abdominal. 

CHAKT 2. 

Quick. Pause. Irregular. Pause. Irregular, 

Respiration for one-half minute in a healthy infant nine months old : awake, but quiet. 

Diaphragm. — In a child three years old Dr. Dwight found the dia- 
phragm to be opposite the lower part of the eighth vertebra, and in another 
child it was at the disk between the eighth and the ninth. Both the chil- 
dren were girls. In a boy of five it was opposite the middle of the ninth, 
and in one of six opposite a point in the lower half of the ninth ; in a girl 
of six it was opposite a point between the ninth and the tenth, and in one 
of thirteen opposite the lower border of the ninth. 

Thymus Gland. — The thymus is most developed in the first two years 
of life, but it persists longer than was formerly taught. During its greatest 
development it is found in the neck as well as in the thorax, extending 
perhaps 2 cm. (f inch) above the sternum, which, you must remember, is no 
small part of the surface of a child's neck. The thymus extends down the 
anterior mediastinum, lying on the pericardium in two long lobes on either 
side of the median line. The extent of these lobes is very variable, and the 
two are not usually symmetrical. I have seen them, even in an infant, so 
developed that the longer nearly reached the lower end of the sternum ; but 
it is very uncommon for it to reach the diaphragm. These prolongations 



NORMAL DEVELOPMENT. 



73 



become thinner as they descend. The thymus is a thick mass behind the first 
piece of the sternum, where it rests on the top of the heart against the great 
vessels concealing the innominate veins, more or less of the superior vena 
cava and the arch of the aorta, and extending back to the trachea. Lower 
down it extends on either side into the angle between the pericardium and the 
lungs, or rather pleurse. Except for the front view, obtained by removing 
the sternum, the size and relation of the thymus are best shown by frozen 
sections. One, made by Dwight, of a child of three years or less, at the 
Harvard Medical School, gives a most remarkable view of it. The section in 
question runs nearly horizontally from the top of the fourth dorsal vertebra 
to just above the junction of the second costal cartilage with the sternum. 

The cavity of the thorax seems to be divided into three parts, one on 
either side of the lungs and a median one occupied by the thymus, the trans- 
verse part of the arch of the aorta, with the superior vena cava on its right, 
and the trachea and oesophagus behind. The area occupied by the thymus is 
very nearly equal to that of the left lung. The thymus reaches backward 
on the left of the aorta behind the level of the front of the spinal column. 
There is also what seems to be a piece of it between the vena cava and the 
trachea. On the upper surface of the same section, at about the level of the 
sterno-clavicular articulations, it is in front of both innominate veins and 
behind the right one. The lungs are prevented from approaching each 
other so nearly behind the manubrium as they do in the adult. 

EiG. 18. 




Frozen section, child of three years : RL marks right lung ; LL marks left lung ; T marks thymus 
gland ; G marks gullet ; OS marks superior vena cava ; AA marks aortic arch ; VA marks vena azygos ; 
F marks some fluid which happened to he in the right chest ; BT marks bifurcation of trachea. (Dwight.) 



The section of the child just described shows that behind the manu- 
brium there is much more of the thymus to the left than to the right of 
the median line, and its dulness on percussion must have been evident at 



74 PEDIATRICS. 

the left of the sternum. Below it merges into the cardiac dulness, and 
no distinction between them is possible. 

The theoretical results of enlargement of the thymus are very serious. 
Resting on the anterior and weaker ventricle, Avhich is prolonged upward 
into the pulmonary artery, it may interfere with the pulmonary supply of 
blood, and by compressing the innominate veins and the superior cava it 
may interrupt the return of venous blood to the lungs. Whether or not 
it may compress the thoracic duct is doubtful, but it certainly may press on 
the trachea. 

The thymus is said often to persist for several years after puberty, but 
observations are not numerous on this point. It seems to disappear from 
the neck and from the front of the heart and to remain longest behind the 
first piece of the sternum. 

For fm-ther information on this subject, I shall refer you to Dr. A. 
Jaoobi's excellent monograph on the Anatomy and Pathology of the 
Thymus Gland. 

Heart. — It is generally held that in the first year of life the long axis 
of the heart is more nearly horizontal than later. The apex is thought by 
many to be higher. I am inclined to think that this is true in the first 
few years, but somewhat later it may be found in the adult position, or, in 
cases where the lower part of the sternum is backward in development and 
the cartilages crowded together, it may be in a lower space than normal. It 
is not unlikely that a subsequent change in these portions of the walls would 
correct this. Thus, if in the early condition the apex were at the sixth 
intercostal space, a lengthening out of the lower end of the sternum might 
cause such a descent of the ribs as would bring it into the fifth space. 

Weight. — As sho^\'Ti by Boyd, the weight of the heart in proportion to 
that of the whole body does not vary much at different ages, so that the rela- 
tive labor of the heart does not materially diifer between the young subject 
and the adult. In the first few years, however, the increase of the weight 
of the heart is greater than at about the fourth or fifth year, and this increase 
is again greater at about puberty. These are facts of practical importance 
to be remembered when we are studying the diseased conditions of the heart. 

TABLE 14. 

Weights of the Heart during its Development. (Boyd.) 

Age. Grammes. 

At birth 20.6 

IJ years 44.5 

3 years 60.2 

5J years . 72.8 

lOJ years 122.6 

17 years 233.7 

I should now like you to examine careflilly this heart of an infant in the 
early weeks of life (Figs. 19 and 20), at a period when the heart and blood- 
vessels have completely changed from the foetal type to that of the adult. 




1-^ 




% 









NORMAL DEVELOPMENT. 75 

It has been prepared by Dr. Franklin Dexter to show the different cavities 
and also the remains of the foetal conditions. First^ looking into the right 
auricle (Fig. 19), you see the remains of the Eustachian valve, and the 
distinctly outlined but closed foramen ovale. Next, on turning the heart 
around (Fig. 20), you see this small tense cord connecting the aorta and the 
pulmonary artery. This is the obliterated ductus arteriosus, and, as you see, 
it pulls the aorta somewhat out of line, a condition which you will find to 
be of considerable significance when we are studying diseases of the heart. 

Blood- Vessels. — Jacobi, in speaking of the extensive work of Thoma 
on this subject, writes as follows : 

" According to a number of actual observations made by R. Thoma, the 
post-foetal growth is relatively smallest in the common carotid, and largest in 
the renal and femoral arteries. Between these two extremes there are found 
the subclavian, aorta, and pulmonary arteries. These are differences which 
correspond with the differences in the growth of the several parts of the 
body supplied by those blood-vessels. In regard to the renal artery and the 
kidney, it has been found that the transverse section of the former grows 
more rapidly than the volume and weight of the latter. Thus, it ought to 
be expected that congestive and inflammatory processes in the renal tissue 
were almost predestined by this disproportion between the size of the artery 
and the condition of the tissue. Moreover, the resistance to the arterial 
current offered by the kidney substance depends also upon the readiness 
with which the current is permitted to pass the capillaries. It has been 
found experimentally that within a given time more water proportionately 
can be squeezed through them in the adult than in the child. These ana- 
tomical differences may therefore be the reason why renal diseases are so 
much more frequent in infancy and childhood from all causes, with the ex- 
ception of that one which is reserved for the last decades of natural life, 
atheromatous degeneration.'^ 

Pulmonary Artery. — Professor Dwight has found the origin of the 
pulmonary artery at ten months to be near the top of the first intercostal 
space and at the same age at the level of the second costal cartilage. At 
three years he found it near the lower border of the first space, also near the 
lower edge of the second cartilage, and again at about the lower part of the 
second space. On the whole, considering the great variations which occur 
in the adult, as recorded by Gibson and others, it is doubtful if there is 
any essential difference at different ages. If we say that in the infant it is 
rather higher than later we have stated about all that is justifiable. 

Lungs. — At what age the lungs reach their full expansion forward has 
not been determined. It would appear that it is not before five or six years, 
and it is probably still later. As the chest expands laterally the lungs of 
course increase, and the relatively greater size of the heart to the lung in 
the infant depends essentially on the size of the lungs. During the first 
year of life (according to Northrup) the alveolar walls are thick and their 
blood-vessels are held loosely. It is not until the fourth or fifth year that 



76 PEDIATRICS. 

the proportionate adult development between the alveoli and the bronchi 
is attained^ and the stroma has become dense and binding, restraining 
the capillaries as in adult life. In infant life the underlying loose tissue 
lining the bronchial tubes gradually binds the mucous membrane to the 
fibro-muscular wall. From this time it keeps pace in its growth with the 
other compact tissues, until in adult life it appears as dense fibrous bands. 
During the first two years the air-cells have not attained the proportionate 
capacity which exists in adult life, and the bronchial tree is still large in 
proportion to the dilating and multiplying alveoli. Again the air-spaces 
developed from the terminal bronchi have covered themselves with a 
continuous layer of flat nucleated epithelium. In its subsequent growth 
in adult life it is believed that the expanding alveolus does not increase its 
number of epithelial cells to cover the more extended wall, but somewhat 
enlarges their size, and, still further, that some of the flattened epithelium 
loses its nuclei and expands to form large, very thin plates, called respira- 
tory epithelium. 






Stomach, spleen, and pancreas at 10 months. Natural size, ixisterior view. S marks the spleen ; P marl 
the pancreas ; D, the duodenum. ^Yarren Museum, Harvard Univemty. 



NORMAL DEVELOPMENT. 77 



IvKCXURK IV. 

ABDOMEN. — TEMPERATURE. — PULSE. — RESPIRATION. — HEIGHT. — 
WEIGHT.— FEET.— BONE MARROW.— SKIN.— CORD.— FUNCTIONS. 
—BLOOD. — LYMPHATIC SYSTEM. — URINE. — INTESTINAL DIS- 
CHARGES.— INFANTILE SKELETONS.— NORMAL INFANTS.— TOPO- 
GRAPHICAL ANATOMY OF THE EARLY PERIODS OF LIFE. 

ABDOMEN. — Liver. — The liver is, as I have told vou, proportion- 
ately large at birth and in early childhood, and, as I shall presently show 
yon on the living subject, can be felt below the edge of the ribs in the 
right hypochondrimn, its border being about 1 or 2 cm. (f to f inch) below 
the lower rib. 

Gall-Bladder. — The fundus of the gall-bladder, according to McClellan, 
is in relation to the surface of the body about that of the ninth costal 
cartilage near the border of the right rectus muscle. 

Spleen. — There is nothing especially to be noted in the spleen in child- 
hood, as it corresponds in its position to that of the adult. According to 
Foster, the spleen grows rapidly in early infancy, but in proportion to that 
of the adult is both absolutely and relatively smaller. It is said that the 
spleen when enlarged encroaches more upon the thoracic cavity than in 
the adult, owing to the greater resistance offered by the costo-colic fold 
of the peritoneum upon which it rests. My clinical experience, how- 
ever, does not especially support this view, as in many cases of enlarged 
spleen from varied causes which I have met in infants it has always 
seemed to me that the abdomen was encroached upon to a greater extent 
than in adults, and that both the physical and the rational signs of the 
enlarged spleen in the thorax were relatively insignificant and often difficult 
to detect. 

Pancreas. — The function and the anatomy of the pancreas correspond 
very closely to those of the salivary glands. It is situated in front of the 
first lumbar vertebra, behind the stomach, and, according to the variations 
produced by age and the grovi:h of otlier parts, lies somewhere between 
the umbilicus and the ensiform cartilage. 

The relative position of the spleen and pancreas to the stomach and 
duodenum is very beautifully shown in these organs obtained at the autopsy 
of an infant ten months old, which lately died in my wards. You see that 
the spleen is behind the cardiac end of the stomach, and very near its ex- 
tremity (Fig. 21, organs seen from behind). You will also notice how the 
pancreas extends from the spleen (its tail being in close apposition to the 
latter organ) along the posterior surface of the stomach and somewhat 
upward to the smaller curvature, passing behind the duodenum and its head 



78 



PEDIATRICS. 



resting in the concavity of the duodenum. The curve of the duodenum is 
also clearly shown in this specimen. 

Kidneys. — The kidneys are lobulated at birth, as I showed you in the 
specimen taken from an infant three days old. (Division I., Lecture II., 
Fig. 9, page 44.) This condition continues for a long time and then dis- 
appears, the lobulation being represented by the pyramids of Malpighi. A 
few years after birth the position and relations of the kidney approximate 
those of the adult (McClellan). 

Supra-renal Capsules. — The supra-renal capsules are, as I have told 
you in Lecture 11. , relatively large in size, and gradually approach the 
adult proportions as the child grows older. 

Bladder. — Although small at birth, the bladder soon becomes capable 
of great distention. 

Symington, from a frozen section which he made in the median plane 
through the body of a child seven months old, shows the position of the 
bladder, which happened to be distended. It takes up, practically, the whole 
of the lower portion of the abdomen, an observation which at once presents 
to our minds the difficulty of making a correct physical examination of the 
infantile abdomen during life, unless we are sure that the bladder is empty. 



The above fact was strikingly exemplified in this little girl, three years old (Case 18), 

who entered my wards at the Children's 
Case 18. Hospital yesterday. She was sent to the 

hospital for an examination in reference 
to the advisability of an operation to re- 
move an abdominal tumor. On inspec- 
tion, a rounded prominence extending 
from the pubes to 3 cm. (IJ inches) 
above the umbilicus could be plainly 
seen. By palpation the tumor could be 
felt extending from the right inguinal 
region over to the crest of the left ilium. 
The tumor was soft, elastic, and fluc- 
tuating. It was evidently not in the 
abdominal walls, but intra-abdominal. 
The child was said to have been ailing 
for over a week, and to have grown thin. 
She passed her urine frequently, but in 
small quantities. Nothing abnormal had 
been found on an analysis of the urine 
made before she entered the hospital. 
You see I have marked in black the 
outline of the tumor as it appeared on 
entrance. 

Suspecting a distended bladder, I 
had a catheter introduced, and removed 270 grammes (9 ounces) of urine. The tumor 
immediately disappeared, and, as you see, the abdomen is now soft and resonant. 




Girl 3 years old. Distended bladder. 



A practical lesson to be drawn from this case is, that the bladder should 
invariably be carefully examined and emptied before diagnosticating or 



NORMAL DEVELOPMENT. 79 

operating for abdominal disease. I have seen a distinguished laparotomist 
neglect this precaution in a young child while operating for appendicitis, 
and on opening the abdominal cavity cut directly through the walls of 
the bladder. The urine flowing out through the wound was the first indi- 
cation to him that he had failed to appreciate that in early life the bladder 
is essentially an abdominal organ. 

You can see that many peculiarities of the digestive tract may arise from 
the causes which I have already spoken of in Lecture II. Especially to be 
noticed, however, are those which are due to the different proportionate stages 
of development of the parts of the gastro-enteric tract at different ages, and 
to differences in their peritoneal attachments. 

Stomach. — The stomach grows very rapidly, and peculiarities of shape 
appear at an early age. I have seen a stomach of four and one-half months 
which, although small, was relatively broader than in the adult. The adult 
shape, however, is soon acquired. How permanent this may be is as yet 
unsettled. There is no doubt that great dilatation may be induced, and it 
is highly probable that where too small quantities of food are given the 
normal stomach will contract. It is also very likely that certain shapes are 
acquired at a very early period. I have seen in a young child a well- 
marked antrum pylori, — that is, a pouch above the pylorus, which, in ex- 
treme cases, forms almost a separate chamber. It is evident that the clinical 
significance of our anatomical knowledge of the growth of the stomach in 
the first year is very great. This question of growth is, in fact, one of the 
most important factors in the problem of the substitute feeding of infants, 
and a lack of its thorough comprehension often leads to most unfortunate 
results. 

Capacity. — There has been much dispute as to the proper method of 
determining the gastric capacity during infancy. All methods of which I 
know are open to criticism, but I have found that by combining all the 
methods and making general deductions I have arrived at very practical 
conclusions concerning the size of the stomach at different ages. I have also 
found that my results correspond closely to those of others who have made 
careful studies of this subject, notably Fleischmann of Vienna, and Holt of 
New York. One of the methods which I have employed has been a clini- 
cal one, which I shall show you, as I happen to have a wet-nurse Avith a 
healthy baby four months old here in the ward. 

[Case 19.] The mother is healthy, and has plenty of milk in her hreasts. Her milk is 
evidently in equilibrium, and agrees with her baby, who is digesting it well and gaining about 
30 c.c. (1 ounce) a day. Now, if we wish to determine the gastric capacity of an infant's 
stomach at four months we can experiment with this infant. The weight of 30 c.c. (1 fluid- 
ounce) of human milk is very nearly 30 grammes (1 ounce). If then we introduce 30 c.c. 
(1 ounce) of milk into an infant and weigh it immediately before and immediately after the 
introduction, the infant should increase 30 grammes (1 ounce) in weight. This method I have 
proved a number of times to be fairly correct, as you see it is in this especial case (Case 19) 
within four or live grammes. It is well known among those who deal in cattle that when 
fat cattle are transported long distances, as from Chicago to New York, they are found to 



80 PEDIATRICS. 

have lost materially in weight, perhaps thirty or forty pounds. Now, if these cattle are 
allowed to fill their stomachs with water, an increase in their weight will be found corre- 
sponding exactly to the weight of the water which they have drunk. I find that this infant 
(Case 19) weighs before nursing 7030 grammes (15^ pounds). We will now let it nurse 
until it evidently is satisfied, that is, practically until it feels that its stomach is full. I then 
immediately weigh it again, and find that it has increased to 7145 grammes (15| pounds), a 
gain of 115 grammes (about 4 ounces). This would, in a general way, denote that the gastric 
capacity of this especial infant was 120 c.c. (4 ounces). 



Now, if a number of healthy infants of different ages and of average 
weights are fed and weighed in this way, we can approximately by com- 
paring the gains in weight which correspond to the same ages determine 
the gastric capacity for each age. I should not, however, consider this by 
itself a reliable method for determining the gastric capacity, as it is open 
to many objections, which need not be discussed at present. One source of 
error, for instance, is the variation of the infant's appetite, which may cause 
either too great distention or underfilling of its stomach. Another method 
which I have used is the actual measurement of the gastric capacity at the 
autopsy, with suitable precautions to avoid over-distention. Combining these 
methods, I have arrived at certain general conclusions, which I shall give 
you in figures. I have in this way also determined that the stomach grows 
very rapidly in the first three months after birth, grows slowly in the fourth 
month, and is then almost quiescent for about two months. It then begins 
to grow again until it has reached its adult size. Frolowsky's rules for de- 
termining the gastric capacity of young infants approximate in their results 
so closely my own investigations that I have prepared from them this table 
of infants' stomachs at different ages and at different periods of growth. 
The tracings of the stomachs are life-size. Frolowsky shows that the activity 
of the stomach's growth is very great in the first quarter of the first year, 
that it is very slight in the second quarter, and that it again shows a moderate 
activity in the last part of the year. He represents this activity of the 
stomach's growth by the ratio of 1 for the first week to 2J for the fourth 
week and S^ for the eighth week, while it is only 3J for the twelfth week, 
3^ for the sixteenth week, and 3|- for the twentieth week. As a starting- 
point from which to calculate the above proportions I have taken the infant's 
stomach which I presented to you at my lecture on the Infant at Term as 
representing a fair average capacity for this age, 25 to 30 c.c. (f to 1 ounce) 
(page 45, Fig. 10). 

This, of course, is also intended to represent an infant with the average 
birth weight. This table will with its six tracings explain what I have just 
said about the rapid increase in size which the stomach shows at the periods 
I have mentioned (Table 15). 



NORMAL DEVELOPMENT. 



81 



TABLE 15. 

Gastric Capacity in the First Five Months of Life. 




Infant 3 hours old. Capacity of stomach 25 to 30 c.c. (| to 1 ounce). 



II. 




Infant 4 weeks old. Stomach 2^ times larger than I. Capacity 75 c.c. (2i ounces). 



82 



PEDIATRICS. 



IIL 




Infant 8 weeks old. Stomach 3^ times larger than I. Capacity, 96 c.c. (8^ omices). 




Infant 12 weeks old. Stomach 3^ times larger than I. Capacity, 100 c.c. (3| ounces). 



NORMAL DEVELOPMENT. 



83 




Infant 16 weeks old. Stomach 3^ times larger than I. Capacity, 107 c.c. (3.56 ounces). 



VI. 




Infant 20 weeks old. Stomach 3f times larger than I. Capacity, 108 c.c. (3.6 ounces). 



84 



PEDIATRICS. 



In comparing these measurements with actual stomachs, the gastric 
capacity as given for sixteen and twenty weeks is somewhat small. I 
consider, however, that they are extremely valuable to begin with, as it 
is always better to err on the side of giving too little food than too much. 

As has been admirably pointed out by Fleischmann, the gastric capacity 
is greater at the same age in the artificially-fed than in the breast-fed infant. 
This observation, however, in all probability only emphasizes the impor- 
tance of bearing in mind the normal gastric capacity of the different ages, 
and of using this knowledge to prevent the overfeeding which has produced 
so noticeable a difference between the sizes of the stomach in breast-fed and 
in artificially-fed infants. 

Since I have developed my methods of substitute-feeding in connection 
with milk modification, I have no reason to suppose that when the infant's 
stomach has been properly managed, as I can now accomplish in substitute- 
feeding, it is any larger than in breast-fed infants. 

The cause, however, which produces the most uniform individual differ- 
ence in the gastric capacity at the same age is the weight of the infant. I am 
inclined from the results of my own observations in a considerable number of 

Fig. 22. 

T 




stomach of infant 12 months old, natural size. Gastric capacity, 90-105 c.c. Weight, 4289 grammes. 

cases to agree with Fleischmann's statement, that the greater the weight the 
greater the gastric capacity. A good illustration of the correctness of this 
rule has lately come under my notice, where (Case 20) a breast-fed infant of 
twelve months with a stomach (Fig. 22) normal in shape presented a gastric 



NORMAL DEVELOPMENT. 85 

capacity of only 90 to 105 c.c. (3 to 3J ounces). This capacity corre- 
sponded to its weighty 4289 grammes (9 J pounds), about the average normal 
weight of an infant at eight or ten weeks, rather than to its age, which in 
the average infant would present a gastric capacity of 240 cubic centimetres 
(8 ounces). 

I have also had under my care an infant of six weeks whose general 
development and weight corresponded so closely to those of the normal 
average infant of twelve weeks that it was self-evident that the two ounces 
of food which would ordinarily have been the proper allowance, so far as 
the age was concerned, was not sufficient, and that its weight indicated a 
gastric capacity for an allowance of four ounces, which, in fact, it took and 
digested with the greatest ease, while with any amount less than the four 
ounces it was never satisfied. 

It will now, I think, be instructive for you to examine these stomachs 
which from time to time I have obtained at autopsies, and see how they com- 
pare with the measurements which I have just given you. Dr. Townsend, 
who prepared most of these specimens, drew my attention to the important 
fact that in measuring the gastric capacity it should be done before the 
stomach is separated from its mesenteric attachment, as otherwise it is easily 
stretched by the fluid introduced, and will then show a greater capacity than 
would be within the normal limits during life. I have had some of the 
stomachs distended beyond their natural size in order to show you how mis- 
leading it would be to depend for exact results on this method of investiga- 
tion. You will therefore find quite a variety of figures representing the 
gastric capacities, but on the whole they correspond so closely to the rule 
already stated that they corroborate rather than disagree with the other 
methods. It is interesting also to note the different shapes which these 
stomachs represent, as some of them are very different from the usual classi- 
cal figures represented in books. So far as I could ascertain, these shapes 
did not occur from any especial disease, such as would influence the outline 
of the stomach, as has happened in this specimen taken from a case of rha- 
chitis. (Page 849, Fig. 108.) 

(The illustrations represent the actual sizes of the stomachs.) 

Beginning with the youngest subject, an infant three hours old, you see, 
as I have already shown you at a previous lecture (Division L, Lecture II., 
Fig. 10, page 45), that the stomach has the average capacity of the new- 
born, 25 c.c. (|- ounce), although the infant's weight was only 2500 grammes 
(5J pounds). 

The next stomach (Fig. 23, page 86) was taken from an infant two and 
one-half days old, and weighing 4000 grammes (8|- pounds). The gastric 
capacity is 25 c.c. (| ounce). 

This next stomach (Fig. 24, page 86) Avas taken from an infant five days 
old and weighing 3000 grammes (6f pounds). The gastric capacity is 
25 c.c. (| ounce). 

This stomach (Fig. 25, page 87) was taken from an infant seven days 



86 



PEDIATRICS. 



old and weighing 2700 grammes (6 J pounds). Its gastric capacity is 40 c.c. 
(IJ ounces). 

These four stomachs (Fig. 10, page 45, Fig. 23, Fig. 24, Fig. 25), all 
taken from infants within the first week of life, show us at once that we 



Fig. 23. 



stomach of infant 2% days old, natural size. Gastric capacity, 25 c.c. Weight, 4000 grammes. 

cannot always depend on an infant's weight for determining its gastric 
capacity in the early days of life. Thus, the Aveights of 2500 grammes, 
3000 grammes, and 4000 grammes all had the same gastric capacity of 
25 c.c. Again, the weight of 2700 grammes had a greater capacity, 40 c.c, 

Fig. 24. 




stomach of infant 5 days old, natural size. Gastric capacity, 25 c.c. Weight, 3000 grammes. 



than the weights of 3000 and 4000 grammes. We must, however, also 
allow that there might be an error in measuring the gastric capacity. 

Do not for a moment think that I am deducing any rules for growth from 



FORMAL DEVELOPMENT. 
Pig. 25. 



87. 




Stomach of infant 7 days old, natural size (posterior view.) Gastric capacity, 40 c.c. Weight, 2700 grammes, 



this very limited number of cases. You will, however, understand the sig- 
nificance of these figures a little later when we are discussing the feeding 

Fig. 26. 




Stomach of infant 12 days old, distended to hold 80 c.c. Natural gastric capacity, 40 cc. 

of the early days of life. This next stomach (Fig. 26) is from an infant 



ss 



PEDIATRICS. 



twelve days old. I have, unfortunately, lost the record of its weight. 
It represents very well, however, the usual shape and position of the 
stomach in early life, and I have had it distended beyond the limit 
of its normal capacity, so as to show you the great elasticity of the ven- 
tricular walls to which I have already referred. The gastric capacity 
was about 40 c.c. (IJ ounces). As you see it now distended, it holds 80 
c.c. (2f ounces). 

This next specimen (Fig. 27) shows the stomach, duodenum, spleen, and 
pancreas of a well-developed infant five months old, QQ cm. (26 inches) long, 

Fig. 27. 




stomach of infant 5 months old (posterior view). Weight, 6000 grammes. Distended to hold 225 c.c. 
Natural gastric capacity, 120 c.c. S marks the spleen ; P the pancreas ; D the duodenum. 



and weighing by estimate about 6000 grammes (13 pounds). Its gastric 
capacity was about 120 c.c. (4 ounces). I have had it distended so that it 
now holds 225 c.c. (7 J ounces). 



Fig. 28. 




c.c. (10 ounces). 



NOEMAL DEVELOPMENT. 89 

This next stomach (Fig. 29) came from an infant seven months old and 
\;veighing 5500 grammes (12 pounds). Its capacity is 220 c.c. (7^ ounces). 

This stomach (Fig. 30) was taken from an infant nineteen months old 
and weighing 6270 grammes (13f pounds). Its capacity is about 300 c.c. 
(10 ounces). 

I wish you to understand that I do not make any definite deductions from 
the last four cases. The stomach at nineteen months is especially unreliable 
as to its capacity. It was very distensible, and could easily by the mere 
weight of the water be made to hold 450 to 600 grammes (15 to 20 ounces). 
It gives, however, a very fair idea as to how the stomach looks at this age. 
This seven-months^ stomach (Fig. 28) in its capacity corresponds to the 
weight, which is that of an infant of four months, while this other seven- 
months' stomach (Fig. 29) seems in its capacity to correspond to the infant's 
age rather than to its weight, which is that of the average infant at four 
months. 

I have now treated this question of gastric capacity by the more exact 
methods of weighing and careful calculation, and also by the usually inexact 
method of direct measurement. Both methods, however, result in a general 
uniformity of figures and give us very fair data by which we can be guided 
when we come to the question of infant feeding. 

It will be seen that the general principle of activity of growth is well 
represented in these figures. 

The gastric capacity, however, in the third, fourth, and fifth months 
may appear rather small, and considerable differences will arise in the 
measurements of different observers. This, however, only impresses on us 
that we have not yet solved the problem of gastric capacity by any system 
of measurement. When all observers have agreed to make use of a mathe- 
matically precise and constant pressure in measuring the stomach, we may 
possibly arrive at more uniform results. Even then the degree of elasticity 
will be found to differ so greatly in the individual stomach that most diverse 
measurements will result. 

There is no doubt that the value of these calculations lies in making us 
recognize evident changes in the activity of growth at certain periods ; in 
making us allow that great differences arise irrespective of age and weight ; 
in impressing us with the fact that the gastric capacity has been over- rather 
than under-estimated, and in enunciating that more exact clinical observa- 
tions should be employed to reinforce our anatomical and physiological datac 

During the last two and a half years I have been enabled through the 
aid of a milk laboratory to adapt exactly to the apparent needs of the 
infants under my care, as well as to their age and Aveight, the amounts of food 
on which they have seemed to thrive. It will be interesting and instructive 
to compare the following table Avith the figures and calculations which I 
have just shown to you, and thus see if my practical clinical results have 
corresponded to my experimental deductions. 

The following figures represent the average amounts of food taken at 



90 PEDIATRICS. 

different periods during their first year by three hundred and forty-one infants. 
They were all well and strong, of average weight, and all were thriving and 
steadily gaining during the year. They received only stated amounts of 
food carefully ordered by prescription at the Milk Laboratory, and were 
watched with the greatest care to see when they evidently were hungry enough 
to have the total amount of their food increased. Of course the opportunity for 
exact work is almost unlimited where one has a milk laboratory at his com- 
mand, and it has therefore seemed to me that this method of determining the 
gastric capacity is an unusually good one, and one which has never thoroughly 
been carried out before. Before showing you the table of the general averages, 
I will pick out one case to explain the significance of the general figures. 

This infant (Case 21) was fed with the greatest care both as to the 
quality and as to the quantity of its food. The following figures represent 
the amount of food given at each meal from birth to ten months : 

TABLE 16. 

Amounts of Food in an Especial Case. 



Cubic Centi- „ 

^^«- metres. ^^^^^• 

Birth 30 1 

4 weeks 45 IJ 

8 weeks 60 2 

12 weeks 75 2^ 

16 weeks 90 3 

20 weeks 132 4A 



. Cubic Centi- ^ 

Age. ^ Ounces, 

metres. 

6 months 150 5 

7 months 150 5 

8 months 150 5 

9 months 195 6J 

10 months 240 8 



This case shows the necessity for frequent and great increase of the total 
amount in the first four or five months, the comparative quiescence of growth 
in the sixth, seventh, and eighth months, and the increase again in the ninth 
and tenth months. It does not, however, correspond so closely to my pre- 
vious results as does this table, where averages taken from the three hundred 
and forty-one cases already referred to are given. 

TABLE 17. 

Three Hundred and Forty-One Infants fed at the Milk Laboratory. 

Number of Cases for Average Amount of Food at 

Age. each Age. 

Birth 45 

4 weeks 76 

8 weeks 84 

12 weeks 97 

16 weeks 87 * 

20 weeks 86 

6 months 73 

7 months 56 

8 months 54 

9 months 45 

10 months 33 

11 months 28 

In this tahle the same infant has of course been recorded a number of times at dif- 
ferent ages. 



each Feeding. 


C.c. 


Ounces 


29.4 


0.98 


70.5 


2.35 


96.6 


3.22 


118.8 


3.96 


137.0 


4.57 


158.4 


5.28 


171.3 


5.71 


185.4 


6.18 


208.5 


6.95 


226.2 


7.54 


238.8 


7.89 


242.0 


8.07 



NORMAL DEVELOPMENT. > 91 

The whole question of gastric capacity is so closely connected with the 
subject of infant feeding that I shall leave it for the present, and speak of 
it more in detail later, when it will be seen to be of infinite importance in 
our attempts to regulate the substitute feeding of infants. 

Intestine. — Small Intestine. — During the first month after birth, it 
may be reckoned that the small intestine will grow about two feet (about 
sixty-one centimetres), and a like rate of gro^i:h may usually be recorded 
at the end of the second month of extra-uterine life ; but after that period 
its development proceeds in a most irregular manner. Thus, in a child 
of one year the small intestine measured eighteen feet (about five hundred 
and forty-nine centimetres), while in another, aged two years, the length was 
only thirteen feet eight inches (four hundred and seventeen centimetres). 
Again, in a child aged six years the small intestine was no less than t^' entj- 
one feet (about six hundred and forty and five-tenths centimetres) in length, 
while in another child, eleven years of age, its length was fourteen feet 
(about four hundred and twenty-seven centimetres). 

I agree with Mr. Treves that the great variations which appear so early 
in the length of the small intestine bear no relation to the growth of the 
child. They probably depend on the diet. Xot only the quantity but the 
quality of the food is an important factor in the growth of the intestine. 
The amount of residue, also, and the more or less irritating qualities of the 
food, must all have their effect. 

As to the internal structm^e of the small intestine below the duodenum I 
can only say that I confirm the view^ now generally accepted, that Peyer's 
patches are found very early. I have seen them at three days and again at 
thirteen days. 

In another case, sixteen months old, Peyer's patches were found, and one 
of them was five inches long. 

Large Intestine. — Treves has also observed that up to three or even 
four months the length remains the same, but that nevertheless a remark- 
able change occurs. This is that the large intestine grows at the expense 
of the sigmoid flexm-e, which at birth is nearly one-half of the large intes- 
tine, while at four months it has assumed about its permanent proportion. 
Treves found the large intestine to measure at one year two feet and six 
inches (about seventy-six centimetres) ; at six years about three feet (about 
ninety-one and five-tenths centimetres) ; and at thirteen years about three 
feet and six inches (about one hundred and seven centimetres). I find 
among my notes the following measurements of the intestine. 



TABLE 18. (Dwight.) 

Sex. Age. Small Intestine. Large Intestine. 

Girl 13 days. 292.9 cm. 48.5 cm. 

Girl 10 months. 670.0 cm. 78.0 cm. 

Boy 10 months. 435.0 cm. 90.0 cm. 

Girl 3 years. 490.0 em. 84.0 cm. 



92 * PEDIATRICS. 

CcBGum and Ascending Colon, — In about thirty-five observations on chil- 
dren under four years of age, most of them new-born infants, the caecum 
was found in about thirty cases to range from the right lumbar region to the 
lower part of the iliac fossa. It was very frequently found at the junction 
of the rather vague lumbar and iliac regions. More or less would usually 
be found between two parallel horizontal lines, one at the level of the highest 
point of the crest of the ilium and the other at its anterior superior spinous 
process. In five cases the caecum was either in the right iliac fossa or over 
the true pelvis, the fact being that it was so free as to have no fixed habi- 
tation. It is comparatively recently that the truth has been recognized in 
America, England, and France that normally the caecum is at every age 
completely invested by the peritoneum, and that the idea that a large part 
of the posterior surface rests on areolar tissue without any intervening 
serous membrane is baseless, except in rare instances. 

In young children the ascending colon differs in some respects from that 
of the adult. Owing to the high position of the caecum, to say nothing of 
the relatively greater size of the liver, it is very short. There is no ques- 
tion that the ascending colon much more frequently has a mesentery than 
in the adult, and also that a relatively larger portion of the part above 
the caecum is also invested with peritoneum so as to be absolutely free. 
More than once Dwight has seen the caecum and a large part of the ascend- 
ing colon in this condition. As to the question of how frequently more or 
less of the back of the caecum may lack its peritoneal covering, in which 
case of course it is bound down to the parts beneath it, Dwight's observa- 
tions are rather remarkable. Treves in his Hunterian Lectures stated that 
in one hundred observations he never found the posterior peritoneal covering 
wanting. Tuffier examined one hundred and twenty subjects, adults, chil- 
dren, and foetuses, and found the posterior surface uncovered in nine, all 
of whom were old people. I have kept no systematic record of Professor 
Dwight's observations on adults, but have the following report of thirty- 
seven young children. In thirty-three the caecum was completely invested 
with peritoneum. In four children, all new-born or only a few days old, 
the whole or a large part of the back of the caecum was without peritoneum. 

Considering that this condition is much more likely to occur in the 
adult, and that, so far as w^e know, no one else has observed it in the infant, 
I am inclined to think that Dwight's large number of cases (four out of 
thirty-seven) must be considered an accident, such as is liable to happen 
where a series of observations is small. Professor Dwight believes that the 
caecum of the infant and that of the young child are much more movable 
than that of the adult, and are also usually situated higher. 

Vermiform Appendix. — The length and direction of the vermiform ap- 
pendix are very variable. I have found it six and a half centimetres (two 
and five-eighths inches) long in a girl of thirteen days, five and three-tenths 
centimetres (two and one-eighth inches) in one of three years, eight centi- 
metres (three and one-quarter inches) in one of ten months, and seven and 



NORMAL DEVELOPMENT. 93 

a half centimetres (three inches) in a girl eleven weeks old. The vermi- 
form appendix in the first of these cases was so peculiarly placed as to 
deserve a few words of description. Only a small part was free, the rest 
being held by a small mesentery to the caecum and the ascending colon. It 
arose from the posterior side of the caecum, and ran backward to above the 
crest of the ilium, where it entered a little peritoneal pouch in the rear wall 
of the abdomen, and then, turning on itself, ran forward again. The en- 
trance to the pouch was guarded below by a semilunar fold of peritoneum, 
with its cavity looking upward. It would appear from Treves's researches 
that the foetal shape of the caecum is that of a pouch hanging down from the 
point of junction of the small and the large intestine and continued into the 
appendix, which grows symmetrically from the middle. Later, however, an 
irregular growth of one side of the caecum generally leaves the origin of the 
appendix near the end of the ileum. D wight has found that this condition 
usually prevails in the child. The position and direction of the appendix 
are most uncertain. It is, however, I believe, as a rule, on the posterior side 
of the caecum. Its little mesentery passes to its beginning from the caecum 
and is only exceptionally attached to the walls of the abdomen or pelvis. 

The importance of the lymphatic glands about the caecum as possible 
starting-points of inflammation is very great. Tuflier states that the lym- 
phatics of the front of the caecum follow the anterior ileo-caecal artery to 
empty into two glands which he has found constantly in the superior ileo- 
caecal fold, and which are very distinct in the child. The posterior glands 
are also found constantly on the posterior and inner wall of the caecum itself 
beneath the peritoneum, They usually form a group of from three to six. 

Sigmoid Flexure. — Dwight's observations on the sigmoid flexure in in- 
fancy show much diversity. In some cases it is obviously very long, in others 
apparently of about the adult proportions. As he has made accurate measure- 
ments in but few cases, I hesitate to make precise statements, but very fre- 
quently even at birth there was no evident departure from the normal adult 
proportions. A difficulty in this inquiry, which, however, is in itself an 
important point in anatomy, is to decide where the descending colon ends and 
the sigmoid flexure begins. Thus, in a girl of ten months the first impression 
was that the latter was not relatively longer than in the adult ; but it was 
found later that what must be called the descending colon proper was very 
short, ending above the top of the crest of the ilium. This portion, a little 
over an inch in length, had a retro-peritoneal surface. The mesentery then 
began, and was attached obliquely across the psoas down to the front of the 
caecum, where it became the meso-rectum. Thus the greater part of the de- 
scending colon formed one loop or series of folds with the sigmoid flexure ; and 
this is by no means the only time that Professor Dwight has pointed out tliis 
arrangement. This loop which I have just described was also found to bo very 
movable. The greatest breadth of the mesentery was four and eight-tenths 
centimetres (about two inches). In another child of the same age it was seven 
centimetres (about two and seven-eighths inches). I am inclined to think that 



94 



PEDIATRICS. 



even in infants, in whom the sigmoid flexure does not, as a rule, seem large, it 
often has a relatively broad mesentery, allowing free displacement. In tsvo 
children of three years the sigmoid flexure did not seem to exceed the adult 
proportion. 

Descending Colon. — As is well known, the descending colon usually has 
no mesentery, but still one is often found. Lesshaft, in his observations 
made on subjects of many different ages, found it once in six times. Dwight, 
in rather more than twenty infants, found a mesentery to the descending 
colon in about half the cases. It is remarkable that Lesshaft found a mes- 
entery less often in young subjects than in others. I find that a great part 
of the large intestines in infants is less fixed than in adults. I unfortu- 
nately, however, have not had at my command sufficient material to enable 
me to say when the mature condition is reached. 

TEMPERATURE. — The temperature of the infant at term, although 
varying within a slight limit, is usually slightly raised. Very soon, how- 
ever, as would be expected from the tax which is immediately made on its 
vitality by so many new surroundings, the temperature falls rather below 
the normal adult standard. In about a week the normal infant has recov- 
ered its equilibrium, and, if its nutriment has also been properly adapted to 
its digestive peculiarities, it usually presents the average normal adult tem- 
perature, 36.8° C. (98.2° F.). 

TABLE 19. 

Temperature of Infant at Term. 



At birth , 37.2° C. (9 

"Within an hour 36.1°-35.5= 

In about a week .' 36.8° C. (9 



1° r.). 

C. (97= 
!.2°F.). 



-96° P.). 



These figures are the average of a large number, and are subject to great 
variations, as is seen on comparing them with a number of observations 
undertaken at my request by Dr. C. W. Townsend at the Boston Lying-in 
Hospital : 



Age. 

1 day . 

2 days . 
5 days . 

5 days . 

6 days . 

7 days . 
7 days . 
7 



TABLE 20. 

Townsend' s Temperature Observations. 



Temperature 
C 

c 



37.2' 
37.3' 
36.6° C. 
37.5° C. 
37.3° C. 
37.5° C. 
37.2° C. 
37° C. (' 



(99° F.). 


9 days 


(99.2° E.). 


9 days 


(98° F.). 


9 days 


(99.5° F.). 


10 days 


(99.1° F.). 


13 days 


(99.5° F.). 


13 days 


(99° F.). 


16 days 


8.5° F.). 


20 days 



Temperature. 


37.4° 


C. 


(99.4° F.) 


37.1° 


C. 


(98.8° F.) 


36.9° 


C. 


(98.4° F.) 


37.1° 


C. 


(98.8° F.) 


37.2° C. 


(99° F.). 


37.3° 


C. 


(99.2° F.) 


37.3° 


C. 


(99.2° F.) 


37.3° 


C. 


(99.2° F.) 



PULSE. — The pulse in uterine life is, as a rule, somewhat higher in girls 
than in boys, the former being about 130 to 140, and the latter 120 to 130. 
Anything over 130 points towards the female sex, but these figures as a means 



NORMAL DEVELOPMENT. 95 

of distinguishing the sexes before birth are not to be relied upon. At birth 
the pulse soon falls somewhat, and, as I have already told you, may be quite 
irregular. This, as a rule, is merely what we should expect would be the 
result of the sudden and great change which has taken place in the circula- 
tory mechanism, and of the additional force which the heart is called upon 
to supply when it becomes the central station from which the blood is pro- 
pelled. The lungs also are scarcely ready to perform at once their function, 
and are often somewhat more of an obstruction than an aid to the blood- 
current. The pulse in early life, especially during the first year, varies very 
much, but, as a rule, allowing that the girl's pulse is usually rather quicker 
than the boy's, the following table represents pretty well what you may 
expect in males. 

TABLE 21. 

Pulse-Rate for Males. 
Age. Pulse-Beats per Minute. 

Early weeks 120 to 140 

Until 2d year 110 

2 to 3 years 100 

5 to 8 years 90 

From the eighth year up to puberty the pulse gradually acquires the 
adult rate. The pulse in children varies greatly under the many nervous 
influences which are continually affecting it in early life. 

Dr. Townsend has also made a record of the pulses taken in the same 
infants whose temperatures were recorded in Table 20. They, as you see, 
do not especially correspond with the general averages of Table 21, but are 
what you may expect in the cases which you happen to see at random. 

Clinically I have never arrived at very satisfactory results in my obser- 
vations on the pulse in infancy. If, however, you care to investigate this 
subject more thoroughly, I will refer you to the excellent work done on the 
pulse by Keating and Edwards. 

TABLE 22. 

Townsend's Pulse Observations. 

Age. Quiet, Crying. 

1 day 130 158 

2 days 120 156 

5 days 152 164 

5 days 160 

6 days 152 

7 days 120 154 

7 days 160 

7 days 152 

9 days 148 

9 days 160 180 

9 days 156 

10 days 152 ♦ 

13 days 136 

13 days 168 

16 days 168 172 

20 days 168 



96 PEDIATRICS. 

RESPIRATION. — The respiration, although quicker in early life than 
in adults and corresponding somewhat to the pulse, assumes the equilibrium 
of a later period of development much earlier than is found to be the case 
with the pulse. It varies with changes of temperature and with excitement, 
and has its rhythm much more easily affected by diseased conditions than in 
later life. This table represents fairly well what you will usually meet with 
on counting the respirations when a child is quiet. 

TABLE 23. 

Respirations. 
Age. Respirations per Minute. 

At birth 45 

Until the 3d year 15 to 40 

3 to 5 years . 25 

I should now like you to notice closely this infant (Case 22) which is 
lying quietly in the nurse's lap. 

It is a male, eight months old, and healthy. In the first place, you see that its type of 
respiration is decidedly abdominal. Counting the respirations by the rise and fall of the 
ensiform cartilage, which stands out quite distinctly in this case, I find that they vary from 
50 to 70 in the minute. They are also, as you see, quite irregular, and by making with a 
pencil an upward stroke for every inspiration, a downward stroke for every expiration, 
and a horizontal line for every pause, you will find somewhat the same lack of rhythm that 
appears in the infant at term, which I described to you in this way in a previous lecture 
(Lecture II., page 48), and also the rhythm corresponding to that of the infant nine months 
old which I have already shown to you (Case 17, page 72). 

Dr. Townsend has also observed for me the respiration of four cases at 
the Lying-in Hospital, with the following results : 

TABLE 24. 

1. Age, 1 hour Kespirations, 48 to 56. (Awake.) 

2. Age, 2 days " 30 to 52. (Asleep.) 

3. Age, 3 days " 24, 32, 44. (Asleep.) 

4. Age, 6 days " 28 to 40. (Crying.) 

The respiration in all these cases was very irregular, and both abdomi- 
nal and thoracic in type. In the baby two days old the respiration was 
chiefly abdominal. 

HEIGHT. — The average height of the male infant at term, I have 
already stated, is, according to a large number of measurements made by 
Quetelet, Yierordt, and others, about 49.5 cm. (19f inches). These figures 
correspond very closely to those which I have met with in quite a number of 
infants whom I have myself carefully measured. Insufficient nourishment 
and improper food, especially as represented in rhachitic children, seem 
to retard the growth, while, on the contrary, the various fevers seem to 
increase the activity of growth in length, while decreasing the total weight. 
In the first three or four months the growth is proportionally rapid to that 
in the latter part of the first year. In like manner the activity is greater 
in the first month than in the second, and in the second than in the third, 
becoming still less in the fourth, fifth, and sixth months. 



NORMAL. DEVELOPMENT. 97 

The average increase for the first month is about 4.5 cm. (1| in.). 

" " " " " second month is about 3.0 cm. (1^ in.). 

" " " " " third to the fifteenth month is about 1 to 1.0 cm. (J to fin.). 

" " " " " first year is about 20 cm. (8 in.). 

'< " " " " second year is about 9 cm. (3 Hn.). 

" " " " " third year is about 7.4 cm. (3 in.). 

«' " " " " fourth and fifth years is about 6.4 cm. (2f in.). 

" '< " " " fifth to the fourteenth year is about 6 cm. (2| in.). 



The height is about doubled in the iirst six years, and at fourteen years 
the final height has usually been attained to within about one-twelfth. The 
height at different ages will be shown in comparison with the weight in 
Table 27 (page 104), when we are considering the question of weight. The 
growth in height seems to be most active in the spring. 

WEIGHT. — We now come to the subject of weight in children, the 
study of which has deservedly attracted considerable interest and scientific 
research. In quite a number of cases it has been found that the careful and 
systematic weighing of infants gives us warning of the approach of disease 
some days before any other symptoms are evident. This point was very 
clearly illustrated in a case which was under my care at the Infants' Hos- 
pital, and to which I shall refer in a later lecture more in detail (Case 279, 
page 627). This infant entered the hospital to have its food regulated. 
It was apparently perfectly well, but after a few days the daily weighing 
showed that it was losing. This loss of weight continued to be the only 
perceptible symptom for a number of days, when it manifested certain 
nervous phenomena and died a few days later of cerebral thrombosis. We 
sometimes notice a loss in weight preceding a chronic nutritive disturb- 
ance by several weeks, and if the coming disease is an acute one, or is of 
unusual severity, the loss is often sudden and great. You will therefore 
readily understand that the careful and systematic weighing of children may 
be of considerable value in preventive medicine. Thus, if we have noticed 
that a child has without perceptible cause lost weight, we can, by guarding 
it from an exposure which in health would not be too great, prevent it from 
having complications such as of digestion or from cold, and render the coming 
disease milder in its type and more readily dealt with. In a paper on the 
Relation between Growth and Disease, by Professor H. P. Bowditch, these 
changes in weight are especially dwelt upon, and it is apparently shoTvoi that 
this method of determinino^ the onset of the disease is more useful in chronic 
than in acute diseases , though even in the latter class it is not impossible 
that the warning may be given in time to be of use, and to merit the term 
of " danger signal" which has been given to it by Dr. Percy Bolton. Bow- 
ditch shows in this interesting table (Table 25) the rate of growth of a 
girl between two and three years old, and the relation between growtli and 
disease. The figures represent the absolute weight of the child obtained by 
weighing in the ordinary manner, and then deducting the weight of the 
clothes. 

7 



98 



PEDIATRICS. 
TABLE 25. 







Weight. 




Date. 


Age, in 
Weeks. 




















Kilo. 


Lbs. 




1880. 










September 19 . . . 


107 


11.40 


25.08 




October 3 . . 






109 


11.40 


25.08 




November 7 






114 


11.78 


25.91 




Decem-ber 5 . 






118 


12.25 


26.95 


. 


December 12 






119 


12.28 


27.01 




December 26 






121 


11.90 


26.18 




1881. 










January 2 . . . . 


122 


12.15 


26.73 




January 23 . 






125 


11.80 


25 96 




January 30 . 






126 


11.65 


25.63 




February 6 . 






127 


11.55 


25.41 


Enlarged cervical glands noticed February 5. 


February 13 






128 


11.55 


25.41 


Clay-colored dejections February 12-15. 


February 20 






129 


11.95 


26.29 




February 27 






130 


11.75 


25.85 




March 6 . . 






131 


11.94 


26.26 




March 13 . 








132 


12.15 


26.73 




March 20 . 








133 


12 20 


26.84 




March 27 . 








134 


12.41 


27.30 




April 3 . 








135 


11.91 


26.20 


Attack of measles beginning April 5. 


April 10 . 








136 


11.71 


25.76 




April 17 . 








137 


11.98 


26.35 




April 24 . 








138 


12.00 


26.40 




Mayl . 








139 


12.03 


26.47 




May 8 . . 








140 


12.01 


26.42 




May 15 . 








141 


12.34 


27.14 




May 22 . 








142 


12.15 


26 73 


Cold in the head beginning about May 22. 


May 29 . . 






143 


12.09 


26.60 





An examination of this table shows that the child, having grown rapidlj^ 
during the autumn, suddenly, and without any manifest cause, began to lose 
weight about the middle of December. This loss of weight was irregularly 
progressive until February 6, when an enlargement of the cervical lymphatic 
glands was noted, followed a week later by clay-colored dejections. These 
symptoms yielded to appropriate treatment, and the child again gained weight 
rapidly until March 27, when a sudden loss of weight occurred, follow^ed by 
an attack of measles. A subsequent loss of weight m May seems to have 
been associated with a rather severe cold in the head. We have here, then, 
a case in which a disorder of nutrition manifested itself by enlarged glands 
and by clay-colored discharges, but in which these symptoms were preceded 
for several weeks by a progressive loss of weight. It seems not unreason- 
able to suppose that this loss of weight was the first symptom of a disturb- 
ance which afterwards manifested itself by more unequivocal signs. Even 
in the case of the acute attack of measles it will be noticed that the loss of 
weight preceded by at least a week the actual eruption of the disease. You 
must not, however, suppose that loss of weight in a growing child is in every 
instance a precursor of actual disease. The weight of a healthy child is 
liable to oscillation within limits which have not been accurately determined, 
but it may sometimes amount to ten or fifteen per cent, in a week. Children 



NORMAL DEVELOPMENT. 99 

lose in weight and regain their loss in a wonderful manner, so easily are they 
affected by even slight physical disturbances, and so great are their recu- 
perative powers. The weight of boys, as a rule, is somewhat greater than 
that of girls at birth, and remains greater up to the age of puberty, when 
the girl rapidly overtakes the boy, surpasses him, and becomes a developed 
woman very soon, while the boy does not become a man until some years 
after puberty. This fact you will see exemplified in the table (Table 27, 
page 104) which I shall presently show you, and which shows that the 
girls have surpassed the boys in their height at the eleventh year, and 
in their weight at the twelfth year, when they are found to be taller and 
heavier than the boys, as is the case also in the thirteenth and the fourteenth 
year. 

The systematic and frequent weighing of infants during the first year of 
their lives I consider to be of great importance, and fkr more useful as a 
means for determining their nutritive condition than any other one method 
which we know of For many years I have had the infants at the Infants' 
Hospital weighed every day as regularly as they are fed, and a glance at the 
column containing their weights in the various weeks and months gives 
information as to their general health, and serves as a guide to the changes 
which it may be necessary to make in their food. The information gained 
in this way is far beyond what the most careful physical examination could 
disclose. The weight is, in fact, an index of the nutritive processes to such 
an extent that it is representative of the child's well-being, while the height 
gives us information rather as to its cellular activity. I have already stated 
that the normal average weight of quite a number of infants at term is for 
males 3250 grammes (7^ pounds), and for females 3150 grammes (7 pounds), 
and I have also stated that many individual cases occurred where the weight 
was either greater or less than these figures, and yet the infant was healthy. 
The increase in weight is in direct proportion to the original weight, and if 
the original weight is small the gain is usually correspondingly small. This, 
however, is only a general rule, for at times I meet with infants of light 
weight whose gains are remarkably large, and often surpass those of infants 
with a heavier initial birth weight. During the first three or four days of 
life there is usually a loss in weight, and the original weight is in a large 
number of cases regained only in the second week. If it is not regained by 
the third week, we should consider that it is a warning that the nutrition of 
the infant is at fault, and that especial measures should be taken to increase 
its vitality. This initial loss of weight is usually designated as physiological. 
We must not, however, be misled by this term, or place too much confi- 
dence in it, for, as a rule, this initial loss, which often amounts to from 270 to 
300 grammes (9 to 10 ounces) can be accounted for only partially by natu- 
ral physiological causes. The additional loss is evidently pathological, and 
is to be so regarded, in order that we should endeavor to obviate it, and 
thus prevent imposing an additional tax on the infant's vitality at a time 
when any tax whatever should be regarded as serious. Dr. Towusend has 



100 PEDIATRICS. 

made some interesting investigations on this loss of weight at the Boston 
Lying-in Hospital, which show that the infants of primiparse lose about 45 
grammes (1^ ounces) more than those of multiparse ; also, deducting 45 
grammes (1^ ounces) as the average loss from removal of the vernix caseosa, 
the meconium still remaining, that the loss in weight is reduced to 247 
grammes (8|- ounces) in the infants of primiparse, and to 222 grammes (7|- 
ounces) in those of multiparse. The whole loss should include the meconium, 
which is computed to weigh about 60 to 70 grammes (2 to 2^ ounces), so that 
a loss of from 90 to 150 grammes (3 to 5 ounces), which includes also the 
urine, on the first day, can, in a very general way, be admitted to be purely 
physiological. Dr. Townsend's figures also show that although the infants 
of primiparse lose more and are slower to recover the loss than are those of 
multiparse, yet after the second week they overtake and keep pace with the 
latter. The whole question is simply one of nutrition, it being well known 
that the milk of primiparse is somewhat longer in acquiring its equilibrium 
than that of multiparse, but that finally it is equally nutritious. It was also 
found that the presence of the colostrum corpuscles in the milk had some- 
thing to do with the loss or with the failure to gain. Where the colostrum 
persisted the infants lost more than when it speedily disappeared. The colos- 
trum should normally disappear in the first week. Where its presence is 
prolonged into the third week, the infants do not thrive. Townsend cites 
three cases at the hospital illustrating this point : all the mothers seemed 
healthy and had plenty of milk. 

(1) Multipara — no colostrum on third day, — infant's loss 8 ounces. 

(2) " — colostrum until ninth day, — infant's loss 16 ounces. 

(3) Primipara — colostrum until thirteenth day, — infant's loss 14 ounces. 

The average loss in five infants of multiparse where the colostrum was 
absent by the fifth or sixth day was 10 ounces. 

I am indebted to Evetsky and Foster for much valuable information on 
this subject, and quote freely from their writings. The whole nervous sys- 
tem of the young child is much more active and excitable than that of the 
adult. The brain, for instance, besides being fifteen times as large propor- 
tionately in the infant as in the adult, increases with much greater rapidity 
up to the age of seven years than at any other period. In connection, proba- 
bly, with the constructive labors of the growing tissues is the activity of the 
lymphatic system. The absorption of oxygen is said to be relatively more 
rapid than the production of carbonic acid, — that is, there is a continued 
accumulation of capital in the form of oxygen-holding compounds. The 
food represents so much potential energy, but it must be converted into tissue 
before the energy can become vital, and in such conversion a large amount 
of molecular energy must be expended. The metabolic activity is more 
pronounced in the infant than in the adult, and is expended not so much on 
the energy required in the external world as for the rapidly increasing mass 
of tissue. Another reason for the presence of more active metabolism in 



NORMAL DEVELOPMENT. 101 

the infant than in the adult is the necessity of rapid molecular interchange 
to keep up the temperature. The infant having the smaller body, and yet 
the relatively larger surface (the extent of skin thus being proportionately 
greater), it loses more heat proportionately than does the adult, and thus 
suifers more easily from changes of temperature. 

Disturbances of the nutritive processes from these conditions very easily 
arise, and the process of assimilation is much more important than in adult 
life, for the child's activity implies a greater consumption of nutriment in 
the form of food or tissue. The child's equilibrium is thus much more 
easily disturbed than the adult's, and this creates a greater susceptibility to 
disease and less power to resist external influences. This is well exemplified 
by the rule that the younger the individual the greater the mortality. There 
are three times as many deaths in the first half of the first year as in the 
second half, and a large proportion of those dying in the first half year die 
in the first month. Of those dying in the first month, death occurs in a 
large proportion in the first week. A considerable number of the deaths 
which occur in the early weeks of life, especially in the first week, are from 
asthenia. These facts are very significant in connection with the child's loss 
of weight in the early days of life over that which we have just described 
as being physiological. Lack of sufficient nourishment and an unstable 
equilibrium are the factors in the problem which represent this early loss 
of weight. These conditions are enhanced by the state of the mother, 
who, exhausted by the process of labor, is not able to supply a food for her 
infant which is adapted to its sensitive and incompletely developed diges- 
tive function. 

In addition to these manifest causes for loss of weight, we must consider 
that the new-born infant is much more susceptible to external impressions 
than when after the first weeks its various functions have become adapted to 
their new surroundings. 

The whole system is stimulated to greater activity of tissue interchange 
not only by the sudden change of temperature to which the skin is exposed, 
but also by the change from darkness to light, and from silence to a greater 
or less degree of sound. This transient early period of life, therefore, is 
marked by a superactive metabolism, insufficient nourishment, and resulting 
asthenic conditions which are analogous to starvation. This is represented 
as a whole by a loss of weight evidently of a pathological character, in ad- 
dition to that which I have described as physiological. You will, therefore, 
now understand with what care the newly-born infant should be protected 
from too great changes of temperature, too much light, and too much noise. 
The analogy of this statement is found in the sensitive organization and 
habits of the lower animals. In this way only can the digestive function 
be made to correspond to such an extent, in the early days of life, to the 
work which is required of it, as to keep the loss of weight within the 
physiological limit. Starvation, as is well known, proves fatal primarily 
not from the amount of food furnished being too little for the processes of 



102 PEDIATRICS. 

disintegration, but from exhaustion of the nervous system. The endurance 
of the starvation is in proportion to the capability of resistance of the 
nervous tissue. This nervous tissue is so highly sensitive and has such 
great functional activity in the infant, proportionately to the adult, that it 
needs much more nourishment, and succumbs much more quickly to depriva- 
tion from nourishment. Young animals die in a very much shorter time 
when deprived of food than do older ones from this cause. It is not sur- 
prising, therefore, that when the early period of life is represented only by 
hours and days, the various disturbances which would be of minor conse- 
quence at a later period of existence should have a decidedly pathological 
effect and produce a marked loss in weight beyond the natural physio- 
logical loss. The following case, taken from my records of this class, 
exemplifies the practical bearing of what I have just said. 

Case 23. — A male infant was born December 16 at term. It was healthy and vigor- 
ous, and gave no evidence of organic disease. The mother, a multipara, strong and healthy, 
was twenty-eight years of age. Her other children were living and healthy. On the third 
day, December 19, the infant had a slight attack of icterus neonatorum, which disappeared 
in twenty-four hours. On the fifth day, December 21, the weather was very cold and bleak, 
but the infant was taken to church and christened. The church was warm and the infant 
reasonably well protected from cold, but there were a large number of people present, and 
an unusual amount of noise. The infant, on being taken home, immediately began to show 
symptoms of asthenia, and on the following day was found to be cyanotic and breathing 
rapidly, with a subnormal temperature and no apparent organic disease. It died in the 
afternoon. The asthenia seemed to be produced by too early exposure to change of tem- 
perature, light, and sound. 

As a rule, the average daily gain in the first two months should not 
be below twenty grammes (two-thirds of an ounce). I have found at the 
Infants' Hospital that if the gain is less than this the infant, as a rule, is 
being badly nourished, is sick, or is going to be sick. There are, of course, 
exceptions to this rule, and I would here also call your attention to the 
fact that observations of weight including only that of two or three days are 
very misleading, and that it is the week's weight which gives us the fairest 
idea of loss or gain. Thus, I frequently find infants showing a daily gain 
of only five or ten grammes (one-sixth or one-third ounce), or even losing 
fifteen or thirty grammes (one-half or one ounce) on one day, and then gain- 
ing one hundred to one hundred and fifty grammes (three and one-third 
to five ounces) on the next day. From this you will readily understand 
that we should obtain from one day's observation too low and on the next 
day too high an estimate of the nutrition. By the end of the week, how- 
ever, the weights usually equalize each other, and we have fairly correct 
figures to guide us. This table (Table 26) shows about what would be 
expected of the average infant as to weight during the first year. Girls, as 
a rule, gain less than boys, but this is only if they are of ligliter weight. 
The heavy girls make the same large gains as the heavy boys, but, as a rule, 
their initial weight is smaller than that of the boys, and they therefore make 
smaller gains. 



NORMAL DEVELOPMENT. 



103 



TABLE 26. 

General Figures of Weight. 
Weight. 

Pounds. 



^^^- Grammes. 

At birth 3000 to 4000 

From birth to 5 months , . 
From 5 months to 12 months 



Average Gain per Day. 
Grammes. Ounces. 



6.6 to 



20 to 30 
10 to 20 



to 1 



Grammes. 
9,500 



Age. 
At 1 year 

At 7 years 19,000 

At 14 years 38,000 



Weight. 



Pounds. 
20.90 
41.80 
83.60 



[The above figures are on a basis of 3500 grammes (7.7 pounds) at birth, and of a gain 
of 30 grammes per day for the first four months and 10 grammes per day for the last eight 
months of the first year. ] 

Useflil figures to remember are that the initial w^eight is doubled at five 
months and trebled at fifteen months ; also that the weight at one year is 
doubled at seven years, and that this weight is again doubled at fourteen 

CHAKT 3. 



OTOCnOCnOCT'OCnOOiOCnOCiCwiO 



)tOCn<IOtO Cn<lO tC Cn ^J O 

JOOOOO OOO O OOO 



^^ ^n 


^^ ^^ 


"4 ^ it it 


^ s> 


" \ ^^i. ~ 


" \ ^. 


^^ ^^ 


"^^ 15^ 


: : '^^ 'S 


_ s 5^„ 


^^ ^ 


^^^^ '^=^ 


1 ^j^ 


1 ^- 


\ 5^ 


^^ S^ 


^ N:^ 


J s 


\ ^s 


s s 


\ y^ 


^ ^v 


\ N 


- - ^ ^. 


^ S 


^ ^ 


^^ ^^ 


^ S 


^ \ 


L 


i . 


3 




1 V 


\ 


v^ 


\ 




V 


A 




^ 


ih \ 




r 


\ 




r 


it I 


± 1 


i 


i^ 





Name, ... 




=^ 


Date of Birth, June 21. 


I 


Initial Weight, 4650. 




Actual Wt. 


Date of Wg, 


1 


4,500 


June 27. 


•? 


4.612 


July 4. 


a 


4,916 


" 11. 


4 


5,332 


" 18. 


r) 


5,684 


" 25. 


6 


6,004 


Aug. 1. 




6,292 


" 8. 


s 


6,&44 


" 15. 


9 


6,852 


" 22. 


10 


7,172 


" 29. 


n 


7,476 


Sept. 5. 


r^ 


7,802 


" 12. 


IS 


7,994 


" 19. 


14 


8,170 


" 26. 


15 


8,362 


Oct. 3. 


1(1 


8,586 


'■ 10. 


17 


8,912 


" 17. 


18 


9,136 


" -24. 


19 


9,376 


" 31. 


•20 






•21 


9,968 


Nov. 14. 


22 
23 
24 
25 
26 


10,112 


" 21. 


10,912 


Dee. 20. 


28 






29 






80 






31 






32 






33 






34 






35 


11.680 


Feb. 20. 


3(1 


11,904 


'• '27. 




12,032 


March 5. 


38 






39 






40 






41 






f, 


12,544 


April 9. 


44 






45 


12,640 


April 30. 


4t) 






l8 






50 






51 


13.1W 


June 10. 




13.37G 


" 2a 



~4 3C C^ 






Pounds. 



104 



PEDIATRICS. 



years. There are, of course, both gains and losses in weight during the 
year, the weight acting as an index of the disturbances which arise. As a 
rule, what may be called the line of nutrition rises from the initial weight 
in the first week, week by week, up to the fifty-second week. A uniform 
increase is, however, exceptional, on account of the many disturbances, such 
as from food, the dental periods, weaning, improper hygienic care, and the 
contraction of disease. 

Instances of continual weekly gains during the first year have occasion- 
ally come under my notice in both hospital and private practice, and the 
chart on the preceding page (Chart 3) gives the exact weights of a healthy 
male infant fed by a wet-nurse for over a year, and will serve as an example 
of the ideal line of nutrition. 

The infant was gaining so regularly that the weighing was omitted in 
several weeks, which fact is unfortunate, as the weights would probably 
have shown the same uniform gain. A weekly gain is also shown in this 
same chart of a male and a female infant, brother and sister, nursed by 
their mother. The double line represents the boy's weights in the first 
twenty-nine weeks of his life; and the dotted line the girl's weight for 
twenty-one weeks. 

The question of weight is so intimately connected with that of feeding 
that I shall reserve showing you the charts recording the daily weights of 
the infants which for the past ten years I have had an opportunity for 
studying at the Infants' Hospital, until we begin to investigate the general 
principles of nutrition. I have prepared this table (Table 27) to show you 
how at a glance you can determine the average normal height and weight 
of boys and girls from birth to fourteen years. 



TABLE 27. 

Average Heights and Weights from Birth to Five Years, and of Boston School Boys and 
Girls, irrespective of Nationality, from Five to Fourteen Years. 



Boys. 


Age. 


Girls. 


Height. 


Weight. 


■ 


Height. 


Weight. 


Centimetres. 


Inches. 


Kilogrammes. 


Pounds. 


Centimetres. 


Inches. 


Kilogrammes. 


Pounds. 


49.37 


19.75 


3.25 . 


7.15 


Birth. 


48.12 


19.25 


3.15 


6.93 


61.87 


24.75 


6.50 


14.30 


5 months. 


59.12 


23.25 


6.30 


1386 


73.82 


29.53 


9.54 


20.98 


1 year. 


74.17 


29.67 


9.00 


19.80 


84.55 


33.82 


13.80 


30.36 


2 years. 


82.35 


32.94 


13.31 


29.28 


92.65 


37.06 


15.90 


34.98 


3 years. 


90.77 


36.31 


15.07 


33.15 


98.27 


39.31 


17.27 


37 99 


4 years. 


97.00 


38.80 


16.53 


36.36 


103.92 


41.57 


1864 


41.00 


5 years. 


103.22 


41.29 


17.99 


39.57 


109.37 


43.75 


20.49 


45.07 


6 years. 


108.37 


43.35 


19.63 


43.18 


114.35 


45.74 


22.26 


48.97 


7 years. 


113.80 


45.52 


21.50 


47.30 


119.40 


47.76 


24.46 


53.81 


8 years. 


118.95 


47.58 


23.44 


51.56 


124.22 


49 69 


26.87 


59.00 


9 years. 


123.42 


49.37 


25.91 


57.00 


129.20 


51.68 


29.62 


65.16 


10 years. 


128.35 


51.34 


28.29 


62.23 


133.32 


53.33 


31.84 


70.04 


11 years. 


133.55 


53.42 


31.23 


68.70 


137.77 


55.11 


34.89 


76.75 


12 years. 


139.70 


55.88 


35.53 


78.16 


143 02 


57.21 


38.49 


84.67 


13 years. 


145.40 


58.16 


40.21 


88.46 


149.70 


59.88 


42.95 


94.49 


14 years. 


149.85 


59.94 


44.65 


98.23 



NORMAL DEVELOPMENT. 105 

The figures for birth, for five months, and for one year represent my 
investigations, combined with the figures which I have already shown you. 
The figures for the second and third years are taken from a series of investi- 
gations made by Dr. George W. Peckham, of Milwaukee, in the Report of 
the Wisconsin State Board of Health for 1882. The figures for the fourth 
year are approximate averages taken from children of three and five years, 
as no reliable figures corresponding to the others in the table could be found. 
The figures from the fifth year to the fourteenth year were taken from Pro- 
fessor H. P. Bowditch's article on the Growth of Children, in the Twenty- 
Second Annual Report of the State Board of Health of Massachusetts. 
They represent the average figures of a large number of school-children. 

In the preceding table the weights at birth, and in the first, second, and 
third years, were taken without clothing. The ordinary school-clothes were 
worn in the weighing from five to foiu-teen years. 

FEET. — I have already referred in Lecture 11. to Dane's work on the 
infant's foot at term, and I will now tell you what he has to say on its 
development, as it is something which cannot be obtained from any other 
source. 

During the first year of life the muscular tone is steadily improving and 
the foot should show a well-marked arch. In fat babies there may be a large 
adipose pad formed under the internal arch, such that on taking an imprint 
of the sole its internal border may appear straight. Even here when the 
camphor-smoked paper is used there will be a distinct shading, showing that 
the pressure is much less than in true flat-foot, as is so well shown in this 
baby with flat-foot (Lecture II., Fig. 14, page 50). 

In sickly children, or in cases where for any reason the muscular develop- 
ment is interfered with, the foot will remain in a lax condition, or even of 
itself fall outwardly into the valgus position. The sexes are alike. Out of 
eighty-five cases, thirty-five were found to show equally good arches on both 
feet ; in thirty-two the right foot was better formed and in sixteen the left, 
while seven showed a broken-down or badly-formed condition of the arch. 

From the time the child begins to walk there is a distinct breaking down 
of the internal arch, which in most cases is wholly lost, the two feet suffering 
equally. For the next year and a half the feet remain quite flat, yet during 
this period isolated tracings appear in which the arch is never lost. It is 
interesting to note that such are always girls, and therefore presumably lighter 
children. 

During the third year the arch is slowly rebuilt, one foot improving before 
the other, and the female's considerably in advance of the male's. When the 
fourth year has been well entered upon, the feet have reached nearly the adult 
condition, the two feet are alike, and there is no diflerence bet^veen the sexes. 

At the sixth year tlie adult type of foot has practically been attained. 
The following tracings represent the average from a series of five hundred and 
twenty children. Fig. 31 represent?; female feet from one week to eight years, 
and Fig. 32 tracings of male feet from two weeks to eight years (page 106). 



106 



PEDIATRICS. 



Pig. 31. 



: tit 



a ^ 



j^^3 




Tracings illustrative of the development of female feet. Ages, 1 week, 3 months, 1, 1^, 2, 1\, 3, 3^, 4, 5, 6, 

and 8 years. 



Fig. 32. 



1 



< 






.#t 



t 



^ 






/ 

;/ 



5^'^ 










' P. 




•* ^^^ 






vj^ %1 






Tracings illustrative of the development of male feet. Ages, 2 weeks, 3 months, 1, 1^, 2, 2|, 3, 3^, 4, 5, 

and 8 years. 



NORMAL DEVELOPMENT. 107 

BONE MARROW. — In a previous lecture I spoke of the red marrow 
as characteristic of the bones in early life. The marrow of the bones 
at a later period of life changes from red to yellow. This change of red 
marrow to yellow begins, according to Professor Charles Minot, before birth, 
and progresses in each bone from the centre towards the periphery, or in 
long bones towards the end. It begins earlier in the distal bones, and then 
goes on from bone to bone centripetally. Concerning the exact time when 
these changes take place very little is known, and nothing definite. I will 
now show you, for comparison with the infant's bone with red marrow already 
described, this section of an adult bone with its yellow marrow. You see 
that one is quite distinct from the other. (Plate II.) 

SKIN. — In the early weeks of life there are two comparatively normal 
conditions of the skin which may be met with, besides the more common 
shades of pink and red described in Lecture I. They are called Icterus 
Neonatorum and Erythema Neonatorum. 

Icterus ISTeonatorum. — Icterus occurs from a number of causes in the 
new-born infant as symptomatic of disease. There is one form, however, 
which is of so slight a grade and is characterized by so entire an absence 
of pathological symptoms that it is usually looked upon as representing a 
physiological condition occurring in the transition from the intra-uterine to 
the extra-uterine circulatory mechanism. It is to this condition that the 
name icterus neonatorum is given. It occurs in the first few days of life, 
and may not entirely disappear for several weeks. The most common time 
for it to begin is from the second to the third day, and, according to its 
intensity, the usual time of its continuation is from eight to fourteen days. 
It is not accompanied by any special symptoms. The conjunctivae are some- 
what tinged with yellow in a certain number of cases, but it does not seem 
to affect the color of the faecal discharges or to appear in any quantity in the 
urine. 

Careful examinations of the blood in cases of icterus neonatorum fail to 
show any changes beyond what would be expected in the early transitional 
stage of blood development commonly found at this age. 

This infant (Case 24, Plate II.), a male, was born ten days ago. Its weight at birth 
was 3400 grammes (7^ pounds). It now weighs 3200 grammes (7 pounds). It was per- 
fectly healthy at birth, and its skin was of the usual pink color which is seen in healthy 
new-born infants, such as I have already shown you. (Plate I.) On the fourth day of its 
life the skin began to show a yellow color, which soon became intensified, and, although it 
is now beginning to fade away, it represents very well the picture of a physiological icterus 
neonatorum. You will notice especially the yellowish-brown color of the abdomen, and the 
slightly icteric color of the conjunctivas. The urine in this case is apparently'' normal, and 
the fsecal discharges are still tinged with the dark color of the meconium. In another week 
this yellow color will almost entirely disappear, and the skin will assume the natural pink 
color of a healthy infant in the first month of life. Later it will become whiter and more 
like the skin of the older child. 

Among the many conditions which might cause this icterus neonatorum, 
the investigations of Birch-Hirschfeld seem to be the most thorouo^h and to 



108 PEDIATRICS. 

oifer the most rational explanation for this condition. This author says that 
it is difficult to avoid associating the icterus in some way with a disturbance 
of the hepatic circulation, owing to the transfer of its chief blood-supply 
from the umbilical vein. This is especially to be seen when we consider the 
very evident congestion and oedema of the liver, so well described by Weber, 
which occurs in cases in which the circulation through the umbilical cord is 
interrupted before the respiratory movements, by their effect on the right 
side of the heart, afford an adequate compensation. 

The vessels in the hilus of the liver are surrounded by a dense layer of 
connective tissue, which is continued into the organ along the branches of 
the portal vein. In cases where there is venous obstruction in the liver in 
consequence of delayed birth this tissue is the seat of much oedema. A 
broad layer of gray pulpy tissue encloses the vessels and is also seen around 
the umbilical vein in its diaphragmatic portion, extending also to the gall- 
bladder. The microscopic appearances of this tissue are those of oedema 
with more or less abundant accumulation of round cells in the interstices. 
That this swelling of the tissue must compress the bile-ducts is sufficiently 
obvious, and Birch-Hirschfeld has found that not only under these circum- 
stances are the bile-ducts distended, but there may be a positive difficulty in 
squeezing the bile out of the gall-bladder into the duodenum, while in the 
latter there is a manifest deficiency of bile. In cases where death occurs on 
the first day of life, a beginning icterus may be distinctly detected, and 
Birch-Hirschfeld has reported cases demonstrating this condition, and has 
also observed the gradual increase of the jaundice where life had continued 
longer. Birch-Hirschfeld has also shown that the presence of the bile-acids 
may always be demonstrated in the pericardial fluid in fatal cases where this 
icterus neonatorum was present, whereas they cannot be found in other chil- 
dren who do not present a jaundiced condition. This may be regarded as 
strong evidence in favor of the hepatogenic origin of icterus neonatorum. 
1 shall speak of the graver forms of icterus in a later lecture. 

This explanation of the cause of icterus neonatorum must not, however, 
be regarded as conclusive ; for Cohnheim has in a number of autopsies 
made on this class of cases failed to substantiate the conditions described by 
Birch-Hirschfeld. 

The ordinary bathing of the infant's skin is all that is necessary in 
these cases of ictefms neonatorum^ and I have never seen any indication 
for especial treatment of this condition beyond great care in establishing 
the equilibrium between the food and the digestion. 

Erythema Neonatorum. — At birth the skin is exceedingly sensitive 
to external influences, and in every case shows variations in color according 
to the degree of this sensitiveness, and to the greater or less amount of irri- 
tation, whether from temperature or from mechanical causes, to which it is 
exposed. 

The delicate layers of epithelium are commonly thrown off to such a 
degree as almost to represent a physiological desquamation, and it is often 



PLAT: 




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Red Bone Ma 
Netiirai Siz' 





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% Natural S'le 






NORMAL DEVELOPMENT. 109 

several weeks before the normal infantile condition of the skin is reached. 
In quite a number of cases this natural condition becomes intensified, and 
we find a uniform redness of the whole skin, which usually appears in the 
first two or three days of life. In a considerable number of cases this hyper- 
semic condition of the skin gradually fades away in about a week, and is 
replaced by the normal pink color which I have already shown you (Case 2, 
Frontispiece). With many others, however, this red color may be compli- 
cated by the icteric condition which I have just shown you (Plate II.), or it 
may change with many intermediate shades of red and yellow into a pro- 
nounced icterus neonatorum. These infants, which are respectively five, six, 
and eight days old (Cases 25, 26, and 27), show very beautifully the combi- 
nation of these two physiological conditions, while the infant to which I 
shall now call your especial attention represents a typical case of an uncom- 
plicated erythema neonatorum (Plate II., facing page 107). 

This infant (Case 28), a female, was born yesterday. It weighed 3000 grammes (about 
6f pounds). It is now twenty-four hours old, and its weight is the same as at birth. It 
began to turn red when it was twenty hours old, and is now, as you see, of a dull but pro- 
nounced red color all over its face, head, thorax, and extremities. Its temperature and res- 
pirations are normal. The meconium has come away in natural amount. It has begun to 
nurse, and seems perfectly well. 

There are usually no constitutional symptoms in these cases. Where the 
hypersemia is very intense a slight desquamation is at times noticed. It is 
well, therefore, for you to study this rather peculiar red tinge of the skin in 
comparison with the redness of simple erythema, eczema, erysipelas, and 
scarlet fever, which I shall show you at a later lecture, and which, owing to 
the different degree of sensitiveness of the individual skin, may at times 
simulate erythema neonatorum as well as each other. This possibility of 
error must be accepted, since these other diseases have been known to appear 
at so early a period of life, although it is unusual for them to do so. In 
one instance at least, to my knowledge, a case of scarlet fever, which ulti- 
mately proved fatal to another child in the family, was considered by the 
attending physician, when he first saw it, to be a case of erythema neonatorum 
in the second week of life, and yet eventually he admitted it to be the som-ce 
of infection of the other members of the family and of the death of one 
of them. 

The application of a simple powder made up from this prescription, 

Pkescription 1. 
Metric. Apothecary. 

Gramma. 

R Pulv. zinci oxidi 30 1 R Pulv. zinci oxidi ^\; 

Pulv. amyli trit 120 | Pulv. amyli trit ^iv. 

M. M. 

with the use of water without soap on the skin, using enough only for clean- 
liness, until the redness has disappeared, is generally all the treatment that is 
necessary in these cases. 



110 PEDIATRICS. 

CORD. — The cord should be carefully wrapped m antiseptic absorbent 
cotton, and no water should be allowed to come in contact with it. It will 
thus become dry sooner, and will gradually loosen and fall off. 

FUNCTIONS. — The different functions of the infant vary considerably 
as to the time of their development, in the same way that is shown by the 
physical development. It is difficult, therefore, to give exact average 
figures, and in fact my observation of individual cases has differed so often 
from these average figures that I can only warn you that you must allow 
much latitude in stating the proper time for an especial function to develop. 

Voice. — During the first year of its life the average infant uses its 
voice merely in crying to express its discomforts and desires. At about the 
twelfth month it usually begins to enunciate single Avords, and in the middle 
or toward the end of the second year it learns to form short sentences. 
Children vary very markedly as to the time when they really learn to talk 
connectedly, but this is usually accomplished by the third or fourth year, 
though it is somewhat later before they master the details of language, such 
as the proper use of prepositions. 

Mental Impressions. — The infant seldom smiles before the fifth or 
sixth week, the change of expression of the mouth before that time being 
usually an indication of some discomfort. In individual cases, however, 
there is no doubt that the true smile of enjoyment comes earlier, even by 
the fourth week. The infant usually does not recognize objects before 
the sixth or eighth week. Its hearing is soon established. The func- 
tions of TOUCH, taste, and smell I have already told you are apparently 
more or less developed at birth. 

Lachrymal Glands. — The development of the function of the lach- 
rymal glands varies considerably, but the infant will usually be found to 
shed tears when it is three or four months old. I have, however, known 
tears to appear as early as the first month. They do not at first come every 
time the infant cries, so that a number of observations must be made on the 
same individual before deciding whether this function is present. I have 
also noticed that even older infants do not shed tears with each crying- 
spell. These facts are at times quite important to remember, as a suppres- 
sion of the lachrymal secretion occurs where the infant's vitality has been 
profoundly affected by disease, and a return of the tears is an indication 
for giving a favorable prognosis, and often that convalescence is about to be 
established. 

Sweat Glands. — The sweat glands are developed at about the third to 
the fifth week. I have seen an infant in the second week of its life suffering 
so much as to have its circulation seriously interfered with from the high 
temperature of a bath-room where it was being bathed, while the nurse ^vho 
was bathing it was perspiring profusely and was apparently perfectly com- 
fortable. There is, however, a great variation in the time when these glands 
develop, and at times even in the second week of life I have noticed cases 
where the head was seen to perspire quite freely. I have already told you 



NORMAL DEVELOPMENT. Ill 

that my observations lead me to think that in certain individuals the func- 
tion of the sweat glands must be fairly developed at birth. 

Salivary Glands. — The saliva is a secretion which is somewhat 
slow in being established, both in quantity and in its amylolytic property. 
There is not much flow of saliva in the infant's mouth for the first three or 
four months of its life, and even when the function of the glands has become 
so developed that the saliva appears in the mouth in abundance, a com- 
paratively small amount reaches the stomach by being swallowed. It flows 
out of the mouth over the chin, and until the latter part of the first year, 
when its amylolytic action has become established, it probably plays but 
an insignificant role in digestion. The salivary secretion contains a certain 
amount of ptyalin, but its diastatic powers seem to be in process of devel- 
opment, and this should indicate to us that this function ought not to be 
forced into use in digestion until it has become much better established, as 
towards the end of the first year. 

Pancreas. — The amylolytic action of the pancreatic secretion I have 
already told you is but little, if at all, developed at birth. Towards the end 
of the first year the function seems to have become fairly well established, and 
to a degree which will not be harmed by a moderate call upon it for the di- 
gestion of small quantities of starch. The pancreatic power of digesting fat 
also seems to be slight in the early months of life, but to increase gradually 
and to be well established by the end of the first year. 

Bile. — The large size of the liver at birth and during infancy is well 
adapted to the great metabolic activity which is needed for the development 
of this period of life. The investigations of Jacubowitsch show that the 
bile in children is poor in inorganic salts, with the exception of the iron 
salts. It is also distinguished by its small amount of cholesterin, lecithin, 
and fat, and the smaller percentage of its glycocholic and taurocholic acids, 
as compared with the bile of later life. 

BLOOD. — The blood of infants and children is so important a subject 
and will in the future play so great a role in the treatment of their dis- 
eases that I have thought it better to devote an entirely separate set of lectiu-es 
±0 its discussion. I shall, therefore, speak of it later (Division YII.). 

LYMPHATIC SYSTEM.— The high development of the lymphatic 
system in early life is very marked. According to Foster, not only are the 
lymphatic glands largely developed and more active than in the adult (as is 
probably shown by their tendency to disease in youth), but the quantity of 
lymph circulation is greater than in later years. The observations of Kram- 
styk show that particles of fat are very easily absorbed in early life. Brun- 
ner's and Lieberkuhn's glands are only partially developed in early life ; 
the solitary and agminate follicles are rich in lymphoid tissue. 

THYROID. — The thyroid body is relatively greater in the infant than 
in the adult. 

URINE. — The urine, as I have already told you, is small in amount at 
birth, and during^ the first twenty-four hours it is not uncommon to find 



PLATE III. 

A. Intertrigo. 

B. Seborrhcea capitis of infants. 

C. Amoeba coli. Section of mesocolon. (Leitz oil immersion Jg, ocular No. 3.) 

Napkins. 

1. Detritus of uric acid infarction (stain during early days of life). 

2. Meconium. 

3. Breast-milk. 

4. Breast-milk. 

5. Crystals of uric acid and urate of ammonium (hedgehog crystals) taken from 10. 

6. Substitute feeding. Fat, 2 per cent. ; milk-sugar, 5 per cent. ; proteids, 1 per cent. 

7_ a u u 3 u u 6 u u I u 

Q U U U 4 " "7 " " 1 " 

g li u u 4 " "7 " " 1 " 

10. Detritus of uric acid infarction in excess. 

11. Bile-stain. 

12. Color of faeces after bismuth 3 grains every two hours for six doses. 

-^g u a u a 4 a u a u 

14. ii ii u li was omitted for twenty-four hours. 

15. Color on napkin commonly seen, but in this case excessive in amount and patho- 

logical from uric acid. 

16. Color of "clay-colored" faeces. 

17. Color of the change in milk-fed (breast or otherwise) infant's fasces just before or 

just after they are passed (not necessarily pathological). 

18. Pathological color seen in Case 417. 

19. " " " Case 418. . . 



112 



:^^i. 




PLATE III 




' B. 




Copyright I894by J, B.LippincoH Company 



NORMAL DEVELOPMENT. 113 

little or none passed. The function of the kidney begins quite early in foetal 
life, and the bladder has been found to be full of urine at birth. The urine 
which is first passed is usually dark and thick, but it soon becomes of a light 
yellow color, and is generally slightly acid in its reaction. Its specific gravity 
(1010 at birth) falls in two or three days to 1003, and by about the fifteenth 
day is found to be 1006. By the end of the first week and throughout 
childhood the amount of urine passed in twenty-four hours is relatively 
greater than in adult life. This in early infancy may be due to the pre- 
ponderance of liquid food, but is in part the result of the infant's more 
active metabolism, for the urea is also found to be proportionately increased. 
According to Foster, the presence of uric and oxalic acid in unusual quan- 
tities is a frequent characteristic of the urine of children. It is also stated 
that the phosphates are deficient, being retained in the body for the purpose 
of building up the osseous system. The uric acid infarction, which I have 
already referred to, and evidences of which may last for two or three weeks, 
consists of urate of ammonium (hedgehog crystals), amorphous urates mixed 
with uric acid crystals, and some epithelial cells (Plate III. 5, facing page 
112). The variations in the amount of urine which has been computed to 
be passed during the early days of infancy and childhood are very great, as 
the amount in all probability depends very largely on the quantity of liquid 
ingested. It is well, however, for you to have some general idea of the 
normal total amount of the urine at different ages when you begin to study 
the diseased conditions of the kidney. 

The difficulties in accurately measuring the amount of urine excreted by 
very young infants are such that few positive statements can be made as to 
the quantity. It is sufficient to say that it is about ninety grammes (three 
ounces) a day for the first few days, and then rises in amount very rapidly. 

Rietz states that during the first four days of life the urine contains 
more or less albumin, and that this disappears at about the seventh or eighth 
day. It also frequently happens that the first urine that is passed is cloudy. 

The following tables (Tables 28 and 29) give approximate figures for 
infancy and childhood : 

TABLE 28. 
Age. Total Urine in 24 hours, 

2i months 250-410 c.c. (8i-13| ounces) (Pollak). 

5 months 986 c.c. (33 ounces) (Camerer). 

TABLE 29. (Schabanowa.) 

Age. Total Urine in 24 hours. 

2- 5 years 760 c.c. (25 ounces). 

5- 9 years 1043 c.c. (34^ ounces). 

10-13 years 1430 c.c. (47 ounces). 

It is often convenient to know how much urine is excreted for each kilo- 
gramme of body- weight. The following table (Table 30) represents the 
results of some careful work which has been done on this subject ; 

8 



114 PEDIATRICS. 

TABLE 30. (Yierordt, in Gerhardt's Handbuch ) 

Number of c.c. 
Number Average Body- Total Amount of Urine ex- 

Years, of Weight, in of Urine in 24 creted for each 

Cases. kilogs. hours, in c.c. kilog. of body- 

weight. 

3-5, boys 4 13 82 743 53.03 

3-5, girls 4 14.73 708 48.00 

6, boy 1 15.5 1209 78.00 

7, boy 1 22.42 1055 47.06 

11, boy 1 24.0 1815 75.64 

13, boy 1 32.69 756 23.12 

Adults — 63.0 1700 to 1800 28.00 

Urine of Adolescence. — It is well to bear in mind, in connection 
with the conditions of the kidney which exist during the period of develop- 
ment, what has been termed the urine of adolescence. At puberty there 
appears to be a disturbance of the equilibrium of the renal circulation oc- 
curring so frequently, and presenting so distinctively the characteristics 
of a simple hypersemia, that we are justified in looking upon it as a physio- 
logical rather than as a pathological condition. 

This physiological congestion of the kidney is probably closely con- 
nected with the development and increased activity of the uterine circulation 
in the female, and with the prostatic and genital blood-supply in the male. 
The importance not only of knowing that such a condition exists at puberty, 
but also of bearing it in mind when we are called to treat children who are on 
the border-line between childhood and adolescence, is too little recognized, 
and this want of recognition often leads to unfortunate mistakes. Numerous 
instances of the truth of this statement must arise in the practice of every 
physician : so that I need refer only to one of a number of cases of this 
kind which have come under my notice. 

Case 29. — A girl, thirteen years old, was brought to me for advice with the following 
history. She had always been somewhat delicate, but had never had any special disease, 
and was considered to be fairly healthy, until she was twelve years old. She then began to 
grow very fast in height without a corresponding development in weight and general mus- 
cular strength. When she was twelve and a half years old the catamenia appeared, and 
were accompanied by severe pain. This was in November. In December, six weeks later, 
the catamenia again appeared, and were accompanied by considerable pain and general pros- 
tration. The child at this time looked pale and thin, had very little appetite, and was easily 
fatigued. A physician was consulted, who prescribed strong food, such as meat, a tonic, 
and gymnasium exercise. This advice was followed implicitly, and the child was made to 
exercise especially the muscles connected with the abdomen and pelvis three or four times 
a week at the gymnasium, and by daily home exercise, such as lying on the back and raising 
the legs. Under this treatment the child rapidly grew worse, and the catamenia did not 
return in January. The physician then examined the child carefully, with negative results 
until the following analysis of the urine was made (Analysis 1) : 

ANALYSIS 1. 

May^ch 19. 

Specific gravity 1035. 

Keaction Acid. 

Albumin 0.05 per cent. 

Epithelial and hyaline casts were found. 



NORMAL DEVELOPMENT. 115 

The child at this time was thirteen years old. The physician now became much 
alarmed, and informed the parents that their child had a form of Bright's disease. This 
statement completely demoralized the whole family, carrying with it as it did to their 
minds the impression of a fatal issue of the disease. The father, who was just starting on 
an important business trip involving much money, was so distressed that his business was 
entirely thrown aside, as he wished to remain near his child. Under these circumstances 
further advice was sought for, and the case was placed in my hands. A careful physical 
examination revealed nothing abnormal about the child beyond overgrowth, with a result- 
ing anaemic condition. The urine was sent to Professor E. S. Wood for expert analysis, 
with the following result : 

ANALYSIS 2. (Wood ) 

March 21. 

Color Normal, 

Reaction Acid. 

Urophsein Normal. 

Indoxyl Normal. 

Urea . Increased. 

Uric acid Increased. 

Albumin Very slight trace. 

Sugar Absent. 

Bile-pigments Absent. 

Specific gravity . 1023. 

Chlorides Normal. 

Earthy phosphates Normal. 

Alkaline phosphates Slightly diminished. 

Sediment Excess of mucus — a little vagi- 
nal epithelium — an occasional 
hyaline granular and epithe- 
lial cast — an excess of renal 
epithelium — an occasional 
blood-globule. 

Total amount in 24 hours 960 c.c. (a little less than 2 

pints). 

I was enabled from this report to tell the parents that the examination showed simply 
a slight renal hypersemia, the very small trace of albumin and the very few casts all point- 
ing towards that condition and against any serious renal disease. The parents' minds were 
much relieved, but no new treatment was instituted, and, as the child was weak and languid 
and did not appear to be improving, I decided to have another urine analysis made before 
giving any further advice. 

The next analysis showed the following conditions : 

ANALYSIS 3. (Wood.) 

April 4- 

Color Normal. 

Reaction Acid. 

Urophaein Normal. 

Indoxyl Increased. 

Urea Incrpased. 

Uric acid Much increased. 

Albumin Very slight trace. 

Sugar Absent. 

Bile-pigments Absent. 

Specific gravity 1027. 

Chlorides Normal. 

Earthy phosphates Increased. 



116 PEDIATRICS. 

Alkaline phosphates Normal. 

Sediment Much calcic oxalate — much 

vaginal epithelium and uric 
acid crystals — excess of renal 
epithelium — a few blood- 
globules — an occasional hya- 
line and granular cast of 
small diameter with renal 
cells and blood adherent. 

This analysis showed the urine to be so concentrated that the indications for treatment 
were very evident. 

The child was not allowed to go to school or to the gymnasium. She was made to rest 
in bed for several hours twice a day. Her diet was largely milk in considerable quantity, 
meat especially being withheld. She was also made to drink freshly distilled water, 250 c.c. 
(about eight ounces) once in six hours. She was allowed to take a slight amount of exer- 
cise out of doors, but to a very limited degree. 

This treatment, so radically different from what she had previously received, was insti- 
tuted on the ground that while there was no organic disease of the kidneys, yet the hyper- 
semic condition was so pronounced as to show that the renal tubules were being kept in a 
condition of chronic irritation to a considerable degree. This irritation was so prominent a 
factor in the girl's generally debilitated condition that it became for the time being of 
primary importance. The causes for the irritation were very evident. The catamenia were 
just being established ; accompanying this was the irregular and varying congestion of the 
pelvic organs originating with the uterus and ovaries, and extending to the kidneys. In 
addition to this was the adolescent condition so common in children growing too rapidly 
for their general nutrition. The girl had been made to exercise the very muscles whose 
exercise would naturally tend to increase pelvic congestion, and was fed largely on meat, 
which would not tend to lessen the renal congestion. The indications for treatment were 
evidently rest for the pelvic organs and dilution of the irritating concentrated urine which 
was passing through the renal tubules. 

Under this course of treatment the child began slowly to improve. She became less 
anaemic ; her appetite increased, and was less capricious ; she began to gain in weight, 
to sleep well, and to have more strength. On April 11 another analysis was made by 
Professor Wood, with the following result : 

ANALYSIS 4. (Wood.) 

Ap7^il 11. 

Color Normal. 

Reaction Slightly acid. 

Urophsein Diminished. 

Indoxyl Normal. 

Urea Slightly diminished. 

Uric acid Increased. 

Albumin Very slight trace. 

Sugar Absent. 

Bile-pigments Absent. 

Specific gravity 1015. 

Chlorides Normal. 

Earthy phosphates Normal. 

Alkaline phosphates Diminished. 

3ediment Excess of mucus and renal cells 

— few blood-globules — one 
hyaline cast detected (after a 
search of more than an hour) 
— vaginal epithelium. 



NORMAL DEVELOPMENT. 117 

This analysis showed such marked improvement that it was evident that we were 
dealing with an exaggerated physiological rather than with a pathological condition, and 
that our treatment was a wise one. I think it may be of interest to you to follow the 
gradual improvement which took place later, and which resulted in complete recovery in 
about one year from the time when the albumin and general renal irritation were first 
noticed. This improvement is shown in the following table : 

TABLE 31. 

Analysis. May 2. May 6. June 7. 

Albumin Slight trace. Slight trace. Very slight trace. 

Specific gravity .... 1008 1033 1018 

The sediment was very similar in all these analyses, and consisted of mucus and of 
vaginal epithelium, a little secondary calcic oxalate, and an occasional hyaline cast and 
blood-globule. 

A final analysis (Analysis 5), made January 29, enabled me to give the following satis- 
factory report, namely, that there was no evidence of any renal disturbance whatever, and 
that the urine was normal in every way. 

ANALYSIS 5. (Wood.) 

January 29. 

Color Normal. 

Keaction Acid. 

TJrophsein Normal. 

Indoxyl Normal. 

Urea Normal. 

Uric acid Normal. 

Albumin Absent. 

Sugar Absent. 

Bile-pigments Absent. 

Specific gravity 1020. 

Chlorides Normal. 

Earthy phosphates Normal. 

Alkaline phosphates Normal. 

Sediment Vaginal epithelium 

and mucus. 

INTESTINAL DISCHARGES.— The contents of the intestme continue 
to be mixed with meconium for three or four days or a week^ the longer 
time being when the infant is weak and does not nurse well. After this 
time the infantile discharges, which have a characteristic appearance as dis- 
tinguished from those of the older child, appear. It is especially necessary 
for you to familiarize yourselves with their characteristics, as they are an 
important guide to the proper feeding of the infant and are an index show- 
ing whether the food is properly digested and assimilated. When the nutri- 
ment is milk, with the percentages of its different elements corresponding to 
what is normally found in good average human milk, the discharges are of 
a golden yellow color, smooth, unformed, of medium consistency, showing a 
large proportion of water, and sometimes changing on exposure to the air to 
a greenish yellow. They as a rule contain undecomposed bile-pigment and 
bile-salts, while the older child's and the adult's discharges do not contain the 
bile undecomposed. The amount of faecal discharge in the first day of life 
is about forty-five grammes (one and one-half ounces), and increases in the 



118 PEDIATRICS. 

following days to fifty grammes (one and two-thirds ounces). It consists of 
mucus, fat, epithelial remains, and a slight amount of albuminoid material. 
In early infancy there are from two to four discharges daily. As the child 
grows older there are two and finally one in the twenty-four hours. They 
do not lose their yellow color until amylaceous or albuminoid food is given, 
when the different shades of brown begin to appear ; they are not formed 
until something besides milk is swallowed. Starting at birth with the sterile 
meconium, infection by the mouth and rectum quickly occurs, and in a short 
time almost any form of bacteria may be found in the discharges, but chiefly 
such putrefying forms as Proteus vulgaris (Jeffries). With the suckling of 
the infant and the substitution of the refuse of the milk and the secretion 
of the digestive tract for the meconium, a sharp transition occurs. Instead 
of the generally distributed forms, causing decomposition, only two kinds 
of bacilli are now regularly found, the Bacillus lactis aerogenes and Brieger's 
bacillus, the first chiefly in the upper parts of the intestine, the second in the 
lower part. When the infant begins to take a mixed diet, quite a number of 
forms of bacilli appear, among them the Streptococcus coli gracilis, the putre- 
fying green fluorescing, a tetrad coccus, and several kinds of yeast. The 
color of the infantile intestinal discharges when the nutriment is milk alone, 
whether human or animal, seems to depend somewhat on the percentage of 
fat, as you will see by examining these napkins with discharges on them 
produced by milk of varying percentages (Plate III., 3, 4, 6, 7, 8, 9). The 
consideration of the fsecal discharges of the infant is so closely connected 
with the subject of infant feeding that I shall leave anything further which 
I have to say about it until we begin to consider that important branch of 
our medical studies. 

We have now, gentlemen, studied the principal anatomical and physio- 
logical facts concerning infants and children which will be of practical use 
in aiding us to diagnosticate and treat their diseases. Before beginning the 
study of these diseases I should like to present for your inspection some 
actual illustrations of normal infants and children. I have explained and 
shown to you in a general way the normal condition of the external portions 
of the body, and also what it contains. 

INFANTILE SKELETONS. — It may aid you to remember what I 
have said if you will also first examine these two skeletons. One (Fig. 33) 
is the skeleton of an infant at term. The other (Fig. 34) is the skeleton of 
an infant at nineteen months. 

You see in the younger subject the large head in proportion to the small 
thorax, and the lack of development of the face in comparison with the 
head, which is very evidently due to the rudimentary development of the 
jaws. You will also notice the widely open anterior fontanelle. On examin- 
ing closely the sternum you will see that it is not in one piece, as in the adult, 
but that the centres of ossification with the intervening cartilaginous con- 
nections, which I have already described in a previous lecture (Division II., 
Lecture III.), are well marked. You will also notice what I have not 



Fig. 34. 





Infant at term, sh(t\viny large head, large ante- Intani ai !•.• monilis, showiim lar-r ii. i -' .1 

Tior fontanelle, small thorax, cartilaginous ster- anterior fontauelle, ossilicatiou ot steniuiu, lilled 

.num, tilted pelvis, and bow-legs. pelvis, and straight legs. 

Warren Museum, Harvard University. 



NORMAL DEVELOPMENT. 119 

referred to before in speaking of the pelvis, how it is tilted forward, as com- 
pared with the adult's, and how small and contracted it looks. You will 
observe that the legs are not straight, as in the older child, but show decided 
bowing of the tibia and fibula. This characteristic condition of the legs in 
intra-uterine life is present at birth and continues for some months, the bones 
usually becoming straight by the time that the period of walking has been 
reached. In this skeleton of an infant nineteen months old, you see that the 
legs have developed naturally in their growth and are straight. The pelvis 
still tilts somewhat, but is evidently less contracted, or rather has begun to 
enlarge. The thorax has broadened in comparison with the head, and the 
cartilaginous sternum has become to a large degree bone. The head is still 
large proportionately to the face, although the jaws have developed consider- 
ably beyond what is seen at birth. The anterior fontanelle is, as you see, 
quite small in comparison with the fontanelle of the new-born infant. 

These are the chief characteristics of the infant's and child's skeleton, 
and you will now appreciate this series of infants and children which I have 
carefully selected to impress upon }'0u the ages at which the various stages 
of physical development should naturally be found. 

NORMALLY DEVELOPED INFANTS.— You must not consider 
this exhibition of healthy infants too trivial for your closest study. I 
believe that one of the greatest drawbacks to the proper appreciation of the 
kind of knowledge which is needed to examine children successfully and in- 
telligently when they are sick, is the lack of precise facts concerning healthy 
children. To know at a glance whether it is normal for a child not to sit 
alone or not to stand alone, — to understand its childish actions, whether in 
creeping or in walking, — these are data which will be of infinite use to you in 
your nursery practice. I therefore do not hesitate to occupy a certain amount 
of time in showing you these infants whose physical development and 
strength represent about what you will meet in a large number of average 
individuals at these especial ages. 



This infant, a few hours old (Case 30), is, as you see, absolutely finable to sit up or to 
hold its head up. The swollen condition of the face which is so frequently seen during the 
early hours of life after a prolonged labor is well exemplified here, and will pass away 
naturally by to-morrow. When the head is not supported, it falls in any direction on the 
thorax. You must, of course, impress upon the nurse that care should be taken to support 
the head gently as well as the back in lifting and carrying the infant at this age, and until 
the muscles have developed to a degree which will render it possible for the infant to support 
its own head, or until, as is still more important to remember, it has learned to co-ordinnto 
sufficiently to make use of these muscles. The time when the infant begins to sustain its 
own head varies considerabh^^, certain individuals being decidedly precocious in this respect, 
while others, without showing any sign of disease, are much later in sustaining their heads 
than is the case with the average infant. From two to three months is about the time when 
the normal infant, according to my experience, sustams its head without assistance, although 
this is usually done in a very vacillating way up to the fourth or fifth month. 

This infant (Case 31) is two and one-half months old. It is apparently normally 
developed as to weight, height, and general growth, and, although it cannot sit alone, and 
has to have its back supported, it holds up its head quite steadily. 



120 PEDIATRICS. 

We have now arrived at a period of growth when the infant can be put 
on the floor without having to be held by the nurse. This is usually from 
the seventh to the ninth month. 

The nurse has just undressed this infant and placed it on the floor (Case 32), so that you 
can see it from all points of view. The infant is eight months old, and is normally devel- 
oped. She, as you see, sits alone 'perfectly well ^ and can be allowed to amuse herself on the 
floor without fear of her falling over. 

The next infant which I shall have brought in to show you is a little more advanced in 
its physical development, as it is ten months old. While the one at eight months (Case 32) 
can sit very well, you see that it cannot as yet move about the floor, and in fact does not 
attempt to do so ; but watch how this active infant, ten months old (Case 33), as soon as you 
place it on the floor, turns over on its hands and knees and moves across the floor, rather 
awkwardly, perhaps, and not very fast, but it certainly can be said to creep. It is natural 
for the average infant of from ten to twelve months to move about in this wa3^ The loco- 
motion of infants at this age, however, is not always on their hands and knees. Many 
individuals never creep, but their first efibrts in progression are represented by sitting on 
the floor and dragging themselves along with one leg. 

Now we will see what this next infant^ which is twelve months old 
(Case 34), can do when we place it beside the others. 

This infant has arrived at a period of development when it is strong enough to pull 
itself up and stand by a chair ^ and you see that it immediately performs this feat, and is evi- 
dently very proud of the accomplishment. 

Finally, here is another infant, fifteen months old (Case 35), and normally developed, as 
3^ou will notice if you carefully examine it. The head proportionately to the adult's is still 
large. The thorax is well formed, with the natural curves of the back, and the legs are 
straight. It can walk very well, and although it is rather averse to performing for your 
benefit and is crying, still you see that it can go across the floor to its mother perfectly well 
without falling. The age at which the average infant walks of course varies, and many 
infants never attempt to creep, but begin to walk before they are twelve months old. The 
average infant, however, walks from the twelfth to the fifteenth month. 

TOPOGRAPHICAL ANATOMY OP THE EARLY PERIODS OP 
LIPE. — I have already spoken of the importance, for purposes of diagnosis, 
of recognizing the fact that the organs differ in the space which they occupy 
in the body according to the stage of development of the child. Well- 
marked periods are thus shown to exist by physical examination as well as 
by anatomical research, and the results of these different methods of inves- 
tigation are found to correspond. I have always found that a careful 
consideration of the period of development is of the first importance when 
beginning to make a diagnosis of disease, especially of the heart and lungs. 
The large size of the liver in infants and the comparatively greater propor- 
tionate size of the heart to the lung in the middle years of childhood are 
striking instances of the truth of this statement, and should warn us that 
more than ordinary care should be employed in diagnosticating a pneumonia 
of the right lower lobe behind in infancy, or a dilated heart in childhood. 
Three periods of growth are of especial significance in this connection : 
1. The development of the organs in the first year, especially in the first 
half of the year. 2. A period occurring during the fourth, fifth, sixth, 



NORMAL DEVELOPMENT. 



121 



seventh, and perhaps eighth and nmth, years. 3. The later years of child- 
hood. 

To represent the first period I have taken this infant (Case 36) , seven months old and 
normally developed, and I have outlined in black the principal points both in front and 
behind which will be useful for you to remember when making a physical examination at 
this age. 

Case 36. 





Normal infant seven months old. 



First look at him in front. The plain dark lines have followed the lower margin 
of the ribs and the outline of the ensiform cartilage and manubrium. To the left of the 
lower part of the left parasternal line you will notice a small curved line. This represents 
the absolute dulness of the heart. The relative dulness is very slight, and indeed almost 
imperceptible even on light percussion over the sternum. This area of dulness can almost 
be covered by the end of the finger used for percussion. It is bounded by the fourth rib or 
third interspace above, and is just within the mammary line. There is very fiiir resonance 
under the whole length of the sternum. The interrupted lines represent the upper and 
lower borders of the liver. There is not much to say about the upper line, but the lower 
one is interesting and instructive as illustrating the large size of the liver in early infancy, 
and you see how little of the stomach, which is here represented by a dotted line between 
the edj-e of the liver and the left border of the ribs, is to be reached by percussion. The 
stomach is, of course, in this infant, empty. When full, it comes out much further under 
the edge of the liver. This general idea of its position, however, is very important when 
we come to consider cases of improper feeding where we have to determine whether we have 
a dilated stomach to deal with. The broad black line just above the level of the umbilicus 



122 



PEDIATRICS. 



marks the transverse colon, which in infancy has a relatively low position. The caecum, 
which is marked hy a black circle, stands, as you see, high in the abdomen, near the anterior 
superior spine of the ilium. I have also outlined the upper piece of the sternum and indi- 
cated the clavicle and first rib. On looking at this infant's back you will see that I have 
marked the lower borders of the thorax, the kidneys, and the lower borders of the lungs. 
The left kidney is decidedly higher than the right at this age. "While the lower border of 
the lung on the left comes down as far as the tenth rib, the corresponding border of the right 
lung, owing to the large size of the liver, descends only as far as the ninth rib. 

I shall now show you a child in the second period of growth (Case 37). 
In this middle period of childhood the heart has developed more rapidly 
proportionately than the lungs, and takes up more space in the anterior 
portion of the thorax. 

Ca8e 37. 



'^^» 




-'m^ 



Is ornial development at six years. 



This boy, six years old, and properly developed for his age, presents certain points of 
interest which differ from the infant and the adult, and which should be carefully taken into 
account when we are making a physical examination at this age. You see I have first 
marked the manubrium, indicating the clavicles, the first and second ribs, the ensiform 
cartilage, and the lower borders of the thorax. The area of cardiac dulness is far greater 
than in this infant (Case 36). This dulness should, so far as the sternum is concerned, be 
determined by light percussion directly over the sternum from above downward. In this 
way we can detect the change in the percussion note over the lower part of the sternum 



NORMAL DEVELOPMENT. 123 

better than by percussing from tbe lung to the sternum, since the former is so much more 
resonant that the sounds are more difficult to distinguish and are often misleading. The 
upper resonant part of the sternum, on the other hand, presents an excellent opportunity 
for comparison, and brings out the delicate shades of sound which are needed in getting 
the relative dulness. This relative dulness, however, is usually pronounced under the 
lower part of the sternum in this period of development, and you hear as I percuss to the 
left how it shades off into the absolute dulness of the precordia. Absolute dulness under 
the sternum, unless depending on pathological conditions, is rare even at this age, when 
it is also rare not to have this physiological relative dulness. In this period the dulness 
of the heart extends higher in the left parasternal line than at any other time of life. 
The lower border of the third rib usually marks the upper border of the absolute dulness, 
which extends also to the left parasternal line and keeps well within the mammary line. 
The relative dulness, on the other hand, reaches as high as the lower border of the second 
rib. It then passes to the right under the upper third of the sternum, descends obliquely 
to the fourth right costal cartilage, and then keeps closely to the right parasternal line. 

To the left it extends well out to and perhaps a little over the mammary line. The 
area of dulness in this special boy I have outlined where as I percussed his precordia you 
heard a marked absolute dulness between the mammary and left parasternal lines gradually 
shading into the marked relative dulness of the lower third of the sternum. You will notice 
that this is a far different result of percussion from that which is found in the adult, and 
in this infant (Case 36), where, as I have shown you, there is no dulness under the sternum, 
and the absolute dulness rises only as high as the fourth costal cartilage in the left para- 
sternal line, and the relative dulness only to the third interspace. The relative dulness also 
extends only as far as the mammary line. The impulse of the heart is usually found a 
little higher in infants and in young children, irrespective of these periods, than in older 
children and in adults. 

You will next notice that a much smaller space is occupied at this age by the liver than 
in infancy. This I have indicated by the double line, which rises as high as the fifth rib in 
the mammary line, and to the attachment of the sixth or seventh right costal cartilage to 
the sternum. The dotted line of the stomach, on the other hand, occupies, as you see, a 
much larger space than in the infant. The line of the transverse colon stands proportion- 
ately higher, the caecum rather lower. On examining the back, you see the lower border of 
the right lung is still a trifle higher than that of the left, and comes to about the upper border 
of the tenth rib, while on the left side it extends to the lower border of the same rib. At 
this age the liver has diminished in size relatively to such an extent that the difference of the 
position of the lower borders of the lung is but slight. 

The kidneys are about on a level on both sides. I have also indicated as landmarks for 
your study the first and twelfth dorsal vertebrae. You see that this child is passing through 
transitional stages of physical development, and is gradually approaching the adult type 
of perfected growth. 

This perfected growth, so far as the topography of the organs is con- 
cerned, is reached in the last years of childhood and at about the age of 
puberty. The organs of the child seem at this age, although they have not 
yet acquired their complete growth, to present for purposes of percussion 
the outlines which we are accustomed to see in the adult, Avith the exception 
possibly of the position of the caecum. 

This normally developed boy (Case 38), twelve years of age, illustrates remarkably 
well the relative topographical correspondence of later childhood and adult life. 

I have, as in the boy of six years (Case 37), outlined the manubrium, clavicle, first 
and second ribs, ensiform cartilage, and the lower borders of the thorax. The curved line 
passing up the left parasternal line to the fourth rib and keeping within the mammary line 
marks the absolute dulness of the heart, and corresponds to the topography of the adult's 
heart. The upper line of the liver is, you will notice, found to be about at the level of the 



124 



PEDIATRICS. 



fifth rib in the mammary line, and does not extend beneath the lower border of the ribs, 
but is just below the tip of the ensiform cartilage. The dotted line represents the stomach. 
The spleen has its upper border at the ninth rib, and its lower portion comes down as far as 
the lower border of the eleventh rib. The caecum you will notice is marked in the upper 

Case 38. 





Normal development at twelve years. 

part of the right groin. The transverse colon is about midway between the stomach and 
the umbilicus. Looking at this same boy from behind, you will see that I have marked his 
kidneys and the lower borders of his lungs in about the same relative position as occurs in 
the adult. I have also indicated the first and twelfth dorsal vertebrae. 



These representatives of the normal development of important periods 
of life have not only been carefully mapped out by myself by percussion 
and in accordance with the anatomical knowledge which we possess on this 
subject, but have also been verified by Professor D wight, who has examined 
each child carefully and has satisfied himself that my marking is correct. 
I shall at present say nothing more about these various stages of develop- 
ment, the knowledge of which I hope you have now mastered sufficiently to 
utilize in connection with the subjects to which I shall next direct your 
attention. 



DIVISION III. 

HYGIENE OF THE NURSERY, 



LECTURK V. 

THE NURSERY.— INTERTRIGO.— SEBORRHCEA CAPITIS OF INFANTS. 
—CLOTHING.— FEET AND SHOES.— SLEEP.— OUT-DOOR AIR.— NUR- 
SERY-MAIDS.— SCHOOL.— IMPORTANCE OF CORRECTING DEFECTS 
OF POSTURE.— VACCINATION. 

We have studied the infant at term with regard to its normal anatomy 
and physiology. We have also examined it at different periods of its growth 
ap to the age of puberty. 

I must now, before undertaking to explain and to show to you the 
various diseases of early life, impress upon you the importance of a knowl- 
edge of the care of the infant and child in health. I am accustomed to 
place what I have to say on this subject under the title of " Hygiene of the 
Nursery.'' It is essentially in the nursery that we should study the healthy 
child, as the nursery is its home, where it feels most at ease and behaves in 
the most natural manner. The general hygiene of the child is represented 
in its nursery, and we should therefore by our knowledge and advice so 
direct these questions of nursery hygiene as to give this sensitive, easily 
impressionable young human being the best opportunity to develop into a 
healthy and vigorous adult. 

NURSERY. — We cannot, of course, in every case procure for the child 
the surroundings which are best for it, but we can at least impress on the 
parent what these surroundings should be, and how important they are for the 
general health of the child. The nursery should be high from the ground and 
out of reach of the dampness which arises towards the latter part of the day. 

Sun and Windows. — It should have a sunny exposure and large win- 
dows high enough from the floor to avoid having the younger children con- 
tinually pressing their faces against the glass to look out, and thus frequently 
catching cold from the little currents of air which penetrate most window- 
casings. The mothers often overlook this simple manner of catching cold, 
and wonder how their children, who are so closely watclied, could have con- 
tracted the catarrhal conditions which you will be summoned to treat. 

125 



126 PEDIATRICS. 

Papers and Carpets. — In my opinion it is much better not to have a 
paper on the walls or a carpet on the floor. Young children are very sus- 
ceptible to inhalation poisons, and to organisms of all kinds. Many a case 
of anaemia, naso-pharyngeal catarrh, and stomatitis ulcerosa has in my expe- 
rience apparently arisen from arsenic in the paper. Dust also, with its mul- 
titude of organisms, which with the most careful sweeping it is impossible 
to get rid of, is another source of irritation to the respiratory tract. I shall 
speak of arsenic in the wall-paper later, but here merely state, in support of 
what I have just said, that very minute amounts of arsenic appear to affect 
young children, and that the paper itself is a receptacle for micro-organisms 
which are difficult to eradicate. 

Picture-Mouldings. — It is advisable not to have any picture-mould- 
ings on the walls, as they are a place for dirt to gather which it is impos- 
sible to remove properly. 

Floor. — There should be as few cracks as possible in the floor, and it 
should be smooth, so as to be easily cleansed. The floor, however, should 
not be highly polished, for children frequently fall while playing, and some- 
times quite severe accidents occur in this way. I have known of one little 
boy four years old (Case 39) who broke his arm by simply slipping and 

falling on the floor. It is too 
often the case that blows and 
resulting injuries are over- 
looked because it is thought 
that all children naturally fall 
and strike their heads. This 
little boy, two years old (Case 
40), fell on his nursery floor 

sequestrum from frontal bone, natural size. ChUd two years ^-^ mouths agO. Nothing 

especial was noticed at the 
time, but one week later a swelling appeared on the right frontal bone, and 
later three small ulcers were noticed in the same locality. The child was 
brought to the hospital, and Dr. Augustus Thorndike examined and re- 
moved this sequestrum, 6J cm. (2f inches) long, exfoliated from the right 
frontal bone and extending from the temple and line of the hair backward, 
including a little of the sagittal suture. 

Walls and Ceiling. — I prefer the floor, the walls, and the ceiling to 
be painted. Not only can they then be frequently washed and scrubbed, 
but when the child happens to have any of the contagious diseases, the 
whole room can so easily be disinfected that it saves much trouble and 
expense. 

Rugs. — A rug is desirable in the middle of the room. It should never 
be an antique ; in fact, it is better to have new, simple carpet rugs. The 
rug should not be too large nor too heavy to be frequently taken out into the 
open air and thoroughly beaten. 

Bed. — The child's bed should be iron, painted so that it can be carefully 




HYGIENE OF THE NURSERY. 127 

cleansed by wiping, and its sides, as the child grows older, should always be 
kept high enough, by some simple contrivance, to prevent the child from 
climbing over them. As few hangings and useless curtains, with which the 
mother is usually so desirous of draping the bed, should be used as possible. 

Pillow and Mattress. — The pillow and mattress should be of hair, and 
the latter should be protected by a rubber sheet and aired thoroughly every 
day. Especial precautions should be taken that the child does not kick 
off the clothes at night. It is well for the nurse's bed not to be close to 
that of the child. This entails a little extra trouble on the nurse's part, but 
her breath is not a healthy pabulum for the child's lungs, which require 
fresh, pure air of their own. 

Closets and Drawers. — The child should have its own closet and 
its own drawers. The nurse's belongings ought to be kept in a separate 
room. The closets and drawers should be cleansed at least once a week. 

Furniture. — There should be sufficient furniture in the room for com- 
fort, but stuffed furniture should be avoided. As little as possible that is 
complicated or cumbersome should be kept in the child's nursery. 

Curtains. — Only simple muslin curtains, which can be washed, should 
be used at the windows. 

Heating and Ventilation. — The heating and ventilation of the 
nursery are of great importance. The child requires pure, warm air. The 
temperature of the room can vary somewhat according to the climate, but, as 
a rule, the average should be from 18.8° to 21.1° C. (QQ"" to 70° F.). The 
open wood fire is best both for the character of the heat which it gives, and 
for its value as a means for promoting ventilation. 

Draughts. — We must take into consideration the currents of air in 
the nursery, so that the mother, understanding the atmospheric conditions 
which surround her child, can give the simple directions, which she has 
learned from us, to the nurse. This is by no means an unnecessary precau- 
tion, for one of the worst cases of rheumatism in the hip-joints (Case 41, Divi- 
sion XVIII. , Lecture LIIL, page 1085) which has come under my notice 
was that of a child two years old who was allowed to sit on the floor with its 
back to the open door, and directly in a line Avith the open fireplace. The 
direction of the currents of air between the doors, windows, and open fireplace 
is admirably and scientifically described by Mr. John Pickering Putnam in 
his valuable work entitled " The Open Fireplace," and I have represented 
the direction of the cold-air current in a picture (Fig. 36, page 131) which 
I shall presently show you. If the child is much on the floor, a sheet 
can easily be placed over the cracks of the door ; and plain white sheets are 
always the best articles for screens or portieres. 

Window Ventilators. — A plain piece of wood the width of the 
window, about 10 cm. (4 inches) higli, and made to fit closely to the 
window-sill, is the best ventilator, but is rarely needed wliere a wood fire 
is burning in the room. The upper sash can also be lowered for a few 
inches if more air is needed. 



128 PEDIATRICS. 

Toys. — Remember that a child puts everything that it gets hold of 
into its mouth, so be careful not to allow it to have toys with colors that 
can be soaked off by its saliva, which would perhaps poison it. Toys also 
which are made of woollen materials or of feathers should be avoided, as 
particles easily come ofP them. 

Scales. — The weight of the infant is so important, as I have told you 
in a previous lecture (Division II., Lecture IV., page 97), that I consider 
properly adjusted scales an important part of the nursery equipment. 
The scales which are usually provided are, as a rule, very inadequate for 
the minute and daily weighing, the results of which are at times of such 
great assistance to the physician in the management of the infant's food. 
Never hang an infant in anything on a hook to weigh it. Such weights are 
usually, from the continual kicking of the infant, quite incorrect. Do not 
think that the kitchen grocery scale is good enough for the infant. We can 
aiford to have incorrect and approximate grocery weights, but cannot aiford 
to apply these methods to the growing infant, with its unstable equilibrium. 
The scales should be of a small but solid platform variety, which can be 
placed on a firm table by the tub where the infant is to be bathed, for use 
before the bath. Here are the scales which I am in the habit of using. 
(Fig. 36, platform scales on table, page 131.) 

These scales weigh from four or five grammes (one drachm) up to ninety 
kilogrammes (two hundred pounds). A basket, with a small soft blanket 
lining it, is placed on the platform of the scale, and the naked infant is 
weighed in the basket. The scale is balanced, and the infant immediately 
taken out of the basket without stopping to read the weight, so as not to 
expose it too long while uncovered. When the infant has been dressed the 
scale can be read, and the balance-weight minus the weight of the basket 
and blanket (which can, of course, always be a constant quantity) gives 
us the exact weight. Weighing with the clothes on I have found a very 
unsatisfactory procedure. 

BATHING. — The question of the bath is one which you will frequently 
be asked about, and is indeed of a good deal of importance in the early 
months of life. Unless there is some definite contra-indication, I think that 
an infant should be bathed every morning. The contra-indications are if 
the skin or nails turn blue, or if the infant seems in any way to show symp- 
toms of weakness or lowered vitality after bathing, such as are represented 
by cold extremities and nose, or an unusually quickened respiration. In 
these cases sponging, merely sufficient for cleanliness, is to be substituted for 
the bath. The bathing should be done with celerity, the tub being placed 
on the side of the fireplace opposite from the window, and fronting the 
latter, so as to avoid draughts and insure a good light, care being taken 
at the same time to protect the infant's eyes from a strong light. I will 
now describe to you the manner in which I prefer the details of the bath to 
be carried out. The nurse sits with her face to the light and has the infant 
on her lap, wrapped up in a warm blanket, with its feet towards the fireplace, 



HYGIENE OF THE NURSERY. 129 

and its head in snch a position as regards the window as to avoid having 
too much light in its eyes. 

Temperature of Bath. — The water should vary in its temperature 
somewhat with the age of the infant, but should never be so cold as to cause 
blueness or cold extremities. We must also be careful not to have the 
water too hot, as this has sometimes proved to be injurious. Each infant, 
however, must have the temperature of its bath adapted to its own vitality. 
This table will, in a general w^ay, guide you in determining which tempera- 
ture at each age you had better begin with. 

TABLE 32. 

Temperature of the Bath for Different Ages. 

Age. ^Centigrade. Fahrenlieit. 

At birth 36.6° 98° 

During first three or four weeks 35° 95° 

One to six months 34° 93.2® 

Prom six to twelve months 32.2° 90° 

Twelve to twenty-four months 30° 86° 

Then gradually reduce in summer to 26.6° 80° 

In the third or fourth year, if possible, reduce to 23.8° 75° 

The nurse first washes the face in clear water, keeping the body and 
limbs wrapped up in a warm blanket. She should gently cleanse the nose, 
the corners of the eyes, and the external ears. The nose is especially impor- 
tant, for the infant's vitality is easily affected by occluded nares. The face 
is then wiped with a soft towel. The nurse should then soap, w^ash off, and 
dry the scalp. The sponge and water in the other division of the bathing 
basin are then used for soaping the body and extremities. Especial care 
should be paid to the folds of the neck, the axillae, groins, genitals, and anus. 
The temperature of the water in the basin and bath should be tested from 
time to time with the bath thermometer until the washing is over. The 
proper warmth of the water is to be kept by adding when necessary a little 
hot or cold w^ater from cans within easy reach. 

Tub. — The tub, which is preferably made of rubber hung on a simple 
wooden frame and sufficiently high to prevent needless stooping on the part 
of the nurse, is placed, as I have arranged this room to show you (Fig. 36), 
on the nurse's left, at a convenient distance from her chair. 

Basin. — In front of the nurse is the double washing basin, which, as 
you see, is merely a china basin divided into two compartments, and fitted 
to a wdcker stand, also sufficiently high to prevent the nurse from stooping 
as she uses it. To the right of the nurse is the table, with the scales on one 
end and the toilet basket on the end towards her. 

Soap. — The soap should be white castile, or any kind which is free from 
irritating elements. 

Sponges. — There should be two sponges : one goes in one side of the 
washing basin, and is for the head and face ; the other is to be used in the 
opposite side of the basin, and is for the body and extremities. The body 

9 



130 PEDIATRICS. 

and limbs having been thoroughly and quickly soaped, the nurse should 
gently lower the infant into the clear water in the bath, being careful not 
to frighten it or drop it. This is not an unnecessary warning. I have 
known infants, even in the hands of ordinarily careful mothers, to be 
dropped from the bath or scales, with a resulting permanent injury of the 
spine or hip. After allowing the infant to kick and splash for a few seconds, 
it is taken back into the nurse's lap and carefully dried with a Avarm soft 
towel. Never soap and wash the infant in the bath, but always on the lap. 
Powder. — When the skin is perfectly soft, clear, and in a normal con- 
dition, no powder is needed. Where there is any slight irritation, which, at 
times, is liable to occur when the skin has not been kept sufficiently dry, and 
S!specially if there is a decided redness in the folds of the skin, as of the 
neck, axillae, or groins, this powder can be applied, for which you can write 

the following prescription : 

Prescription 2. 
Metric. Apothecary. 

Gramma. 

5L Pulv. zinci oxidi 7 15 R Pulv. zinci oxidi gii ; 

Pulv. amyli trit 60 | Pulv. amyli trit ^ii. 

M. M. 

No perfume of any kind should be added to the powder. The infant 
should be sweet and pure in itself, without accessory odors. In addition 
to this room arranged to show these various details of nursery routine, 
I have had this diagrammatic picture of the nursery drawn for you to illus- 
trate what I have just said in regard to ventilation and bathing (Fig. 36, 
page 131). 

You see the simple wooden ventilator under the lower sash of the win- 
dow, and the arrows marking the entrance of the cold-air current. Where 
this current is too strong it can be tempered by pinning a towel across the 
opening between the upper and the lower sash. The cold-air current passes 
from the window at a point near the floor directly across the room to the 
open fireplace. This should at once suggest to the mother that parts of the 
room, on account of these currents of air which from doors and windows 
pass over the floor to the fireplace, should be avoided not only for bathing 
but also for playing on the floor. 

A hi^ fender covering the entire opening of the fireplace, and fastened 
so that the older child in playing cannot pull it down, is an important part 
of the nursery equipment. It answers two purposes, — one to prevent the 
sparks from flying out on the child, the other to prevent the child from 
falling into the fire. Serious accidents have happened from a lack of 
proper precaution regarding this apparently self-evident necessity. The 
hot air from the fire radiates in all directions, as is shown by the arrows. 

There should be a rack for the towels, which should be kept warm in 
front of the fire while the infant is being bathed. 

The clothes should in like manner be neatly spread out on another 
rack, ready to be put on as soon as the infant has been dried. 



132 PEDIATRICS. 

The bath thermometer is represented at one end of the tub ; it is usually 
guarded from breaking by a wooden frame, which also allows it to float in 
the water, and the nurse is thus enabled to see at a glance that the bath- 
water is remaining at the proper temperature. 

Clock. — There should be a good clock in every nursery. 

There are two conditions of the skin that quite commonly occur in 
infants, especially in their first year, which, although they are abnormal, 
usually come from lack of sufficient care in the nurses, and can therefore be 
spoken of here rather than among the pathological conditions of the skin, 
which I shall mention later. One is intertrigo, the other the seborrhoea 
capitis of infants. 

INTERTRIGO. — The former, intertrigo, is merely an exaggerated hy- 
persemic condition of the skin, usually of an erythematous type and occurring 
in the folds of the skin. This infant (Case 42, Plate III. A, facing page 
112) represents very well this condition in the groins. Napkins soaked 
in urine and allowed to remain for some time without being changed are a 
frequent cause of this condition. 

Keeping the skin clean and dry and applying the powder will, as a rule, 
soon cure this intertrigo. At times, however, it becomes much more intense 
and runs into a pronounced eczema, which is a much more difficult lesion 
of the skin to deal with and requires special treatment such as I shall 
describe when showing you cases of eczema in a later lecture (Division 
IX., Lecture XXL, page 470). 

SBBORRHCBA CAPITIS OP INFANTS.— The second condition, 
which also can well be described in this connection, is represented by 

This infant (Case 43, Plate III. B), two months old, which I shall now show you. It 
has, as you see, a collection of crusts of a brownish-yellow color on the top of its head. 
These crusts are especially thick over the anterior fontanelle. This condition is called the 
seborrhoea capitis of infants, and you will often be asked whether it is safe to remove it. It 
should never be allowed to collect, and when present it should be gently and gradually 
removed by first soaking it with warm sweet oil to loosen the crusts, and then washing it 
off with soap and warm water. A little simple ointment should be applied to keep the 
scalp at this point soft and thus prevent the reaccumulation of the crusts. The whole scalp 
of the infant should be perfectly clean. Seborrhoea capitis is simply a tendency to over- 
production by the sebaceous glands of their secretion, which, mixed with dirt, produces this 
condition. 

CLOTHING. — It is very important that those who care for the infant 
should not only clothe it properly but should understand why one method 
of clothing is better than another. The surface of the infant's body is 
greater in proportion to its entire weight than is the case in the older and 
hence larger human being. Greater surface means that there is a greater 
opportunity for evaporation, and hence that the smaller subject will cool off 
more quickly, other conditions being equal, than the larger one. We there- 
fore see at once that much care should be given to the question of warmth in 
the infant. Any exposure of the body or limbs in either infants or children 
is unwise. A very important factor in the problem of growth in the infant 



HYGIENE OF THE NURSERY. 133 

is perfect freedom of motion for its legs and arms and for the respiratory 
and abdominal muscles. It should also be thoroughly understood that 
pressure on any portion of the body or limbs must produce evil results, 
by displacing organs which should be allowed to have entire freedom of 
position in their respective cavities. 

Too little warmth will do harm, by preventing the proper metabolism of 
the tissues and thus reducing the animal heat. Too great warmth, on the 
other hand, by causing inequalities in the circulation, will in like manner be 
detrimental to the child's growth and vigor. Clothes which bind any part 
of the infant tightly cannot but press out of their natural position whatever 
happens to be beneath the point of pressure, whether it be the liver, the in- 
testines, or the toes. The clothes, then, must evidently be warm and loose, 
and we must bear in mind that loose clothes are warmer than tight ones, 
from the very fact that they do not interfere with the natural activity of the 
circulation, and that they give freer play to all the muscles w^hich produce 
the normal warmth arising from exercise. We must remember that the 
only way in which the infant can obtain the exercise so much needed for 
proper growth, and which is so easily obtained by the older child in running 
about, is by continually moving its legs and arms and thus accelerating the 
muscular action of its thorax and abdomen. 

An important item in the proper management of the infant in its nursery 
is that it should be irritated as little as possible by unnecessary delay in 
dressing it after its bath. Useless stitches, buttons, and articles of clothing 
should be dispensed with, and a method adopted which, while combining the 
necessities of dress which I have just spoken of, will allow the dressing to be 
finished before it has time to annoy the infant. 

Abdominal Band. — There is no necessity for using beyond the first 
two or three weeks the usual fiannel band supposed to be so indispensable 
by the average nurse. Hernise, whether umbilical or inguinal, cannot be 
obviated, and in fact may be produced, by undue abdominal pressure. 

This form of abdominal band (Fig. 37 A), which is made of light soft 
flannel, can be smoothly applied over the dressing of the cord and kept in 
place with moderate pressure by means of safety-pins. 

The band can soon be replaced by a somewhat elastic knitted garment 
(Fig. 37 E, A), half band and half shirt, with shoulder-straps of the same 
material to hold it in place, and a tab in front to fasten it with a safety-pin 
to the napkin (Fig. 37 E, B). 

This shirt can be made of soft wool or silk, or, as I have recently found, 
can be knitted in any form or size from half cotton and half silk. 

This knit material can also be used for these other undershirts which I 
have here to show you (Fig. 37 B and Fig. 38 F, page 137). Garments 
made in this way are the best that I have ever seen. They are warm, soft, 
and delicate, have no seams, can be washed without shrinking, and retain 
their elasticity much better than those made from the other materials which 
I have mentioned. 



134 



PEDIATRICS. 



Fig. 37. 
[Long Clothes.) 

A 



r^^> 



%\\!\ r.l!'<fe. 



/ 



Flannel band for early weeks. 




Dress. 



A, knit band ; B, napkin ; C, stocking. 



HYGIENE OF THE NURSERY. 135 

Napkins. — This napkin (Fig. 37 E, B, page 134) is folded and fastened 
with safety-pins as is customary for keeping it in place. The usual napkin 
is very cumbersome and heavy, besides being expensive. It can be replaced 
by rolls of soft absorbent gauze, which absorb the urine from the skin, an 
important quality in cases where the skin is easily irritated. These naj^kins 
can simply be cut from the roll, which is kept in the nursery, and, when 
removed from the infant after a movement of the bowels, can be burned, 
thus avoiding the trials resulting from the objections of the nurse or the laun- 
dress to washing the napkins. If, however, the mother prefers the regular 
old-fashioned napkin, small squares of this gauze can be placed in the middle 
of the napkin, and this will in great measure obviate the more disagreeable 
part of the napkin-washing, as the square of gauze will hold most of the 
movement and can at once be burned. 

The infant while in long clothes need not have any further covering for 
its legs, and need have nothing on its feet. There is no particular objection 
to little knit socks if the mother wishes to use them. 

After the nurse has put on the band and the napkin there are left three 
garments which are usually the clothes needed to complete the infant's out- 
fit of long clothes. 

These garments are the shirt (Fig. 37 B, page 134), the petticoat (Fig. 
37 C), and the dress (Fig. 37 D). 

Shirt (Fig. 37 B). — The shirt is a garment with long sleeves and high 
neck, cut almost as long as the outside white slip or dress. Unless it is 
knitted, as I have before described, it is well to have it made of some soft, 
fine, all-wool material, with the seams finished on the outside to prevent 
irritation of the skin. It is made to button in the back. A fresh garment 
of this kind is also sufficient for the infant's dress at night, except during the 
early weeks of life. 

Petticoat (Fig. 37 C). — A flannel shirt cut all in one piece, as the 
shirt is, made of fine flannel with no sleeves and with low neck, represents 
the petticoat. It should be made large enough to go over the shirt, should 
be of the same length as the dress, and should also be made to button in the 
back. The taste of the mother can be gratified by any reasonable degree of 
embroidery which she may wish to put on this second garment, but the shirt 
should be perfectly plain. 

Dress (Fig. 37 D). — The outer garment should be made of some soft 
white material, such as nainsook, should be large enough to go over the shirt 
and petticoat, should not be starched, and is usually about one yard long 
from the neck to the bottom of the skirt. It should have high neck and 
long sleeves, and should button behind. 

The advantage of this costume is that it is loose but warm, and that the 
three pieces which constitute it can be put on together, the infant having to 
be turned over only once before the clothes are buttoned. The other metliods 
of clothing usually necessitate turning the baby over several times in the 
process of dressing. 



136 PEDIATRICS. 

Before the infant has had its bath, these three articles of dress are to be 
arranged one inside of the other, ready to be slipped on all three at once. 
This can be done with great celerity, and the dressing process can thus be 
gone through without the usual accompaniment of irritated cries which are 
so frequently heard in the nursery, and which are to be deprecated. 

When the infant is old enough to have its long clothes changed to short 
ones, which is at about the time when it learns to creep, the under-garment can 
be rejilaced by a knitted or fine all-wool undershirt with high neck and long 
sleeves (Fig. 38 F, page 137) made short, with an additional white petticoat 
in winter if desired. The infant should now also have its feet and legs 
covered with long white wool stockings, which are kept in position by being 
pinned to the napkin (Fig. 37 E, B, page 134). When the child begins to 
walk, soft kid shoes should be used with the soles adapted to the natural 
curves of its feet, as I have explained in a previous lecture (Division II., 
Lecture IV., page 105), and as I shall presently show you (page 139). 

Stockiis^gs. — A word more in regard to the stockings may not be out 
of place, and is especially needed in reference to the older child in its third, 
fourth, and fifth years. It is a mistake to think that if we keep the feet 
and abdomen warm the legs can be left uncovered with impunity. Short 
stockings and bare legs, in my opinion, should be abolished, as a prolific 
source of catarrhal conditions. The argument is a poor one that certain 
children have been known to grow up well and strong with uncovered legs, 
or even that our ancestors were in the habit of depriving their children of 
suitable coverings for their necks and arms as well as legs, while they them- 
selves were warmly clothed from head to foot. Our ancestors did and said 
many things which, to us, convict them of great ignorance. I have said 
that the stockings should be white. This is to insure freedom from poison- 
ous dyes, which at times seriously affect the delicate skin of the young child. 
Colored stockings are a source of great gratification to lazy nurses and to 
those who wish to lessen the size of their laundry. 

There are three garments which are usually put over the shirt and are 
considered to complete the short clothes. These are the flannel petticoat, the 
white petticoat, and the dress, and they are to be made large enough to fit 
one over the other and thus to be put on all at once. 

Flannel Petticoat (Fig. 38 G, page 137). — The inner garment 
next to the shirt has a flannel skirt, a cotton waist, low neck, no sleeves, 
and is fastened with buttons in the back. 

White Petticoat (Fig. 38 H, page 137). — Next to the flannel petti- 
coat comes a garment with a skirt of some soft white material, with a cotton 
waist, low neck, no sleeves, and also buttoned in the back. 

Dress (Fig. 38 I, page 137). — Finally, over all the other garments 
comes the dress, which is made with high neck and long sleeves, and is 
buttoned behind. 

Night-Dress (Fig. 38 J, page 138). — A regular night-dress can 
now be used, made of soft flannel, with high neck and long sleeves, and 



hygie:n^e of the nursery. 



137 



Fig. 38. 
{Short Clothes. 

F 




Shirt. 





Flannel petticoat. 



White petticoat. 




Dress. 



138 



PEDIATKICS. 




Night-dress. 

buttoned behind. An extra garment can in cold weather be worn under the 
night-dress if deemed advisable for the especial child. 

FEET. — I have already spoken somewhat at length about the instep, 
and how important it is to guard it from the usual injudicious treatment 
which it receives. In young children, although the foot may be well formed, 
it is very weak, so that the arch is easily broken down. The pad of fat to 
which I have previously referred (Division I., Lecture II., Fig. 13, page 50) 
is a physiological protection against such breaking down. Children should 
not be allowed to walk until some time after they are ready to do so, always 
allowing, of course, that if they insist on walking they can seldom be re- 
strained from doing so. As they get older, long walks with their parents 
should, if possible, be forbidden, for it is through these long walks that the 
evils which I have just endeavored to explain to you are brought about. The 
child will get exercise enough at its play, and in doing so will not overtax 
the arch of its foot, or use its feet beyond the degree which nature intended. 
Children should not be told to turn the toes out too much, as this puts the 
arch in a position where the muscles give it least support. The average 
dancing-school master is a fair example of what over-zealous ignorance com- 
bined with the respected traditions of the past can do to children's feet. 

SHOES. — Children's shoes should be rights and lefts, like those of adults, 
as the present style of straight shoe gives no support to the arch during a 



HYGIENE OF THE NURSERY. 



139 



very important period of its growth ; this, moreover, also tends to push the 
great toe towards the median line of the foot, and so to cause enfeebling of 
the muscles which have so much to do with the proper elasticity of the feet. 
We should, therefore, have shoes properly adapted to the child's foot, — 
shoes that will at once be comfortable and leave the feet free to develop and 
fulfil all their functions. The children's shoes as we find them in the stores 
have the two sides of each shoe symmetrical and equidistant from the 



Case 44. 



Fig. 39. 
(Natural size, 1^ years.) 




Unsuitable shape for sole of child's shoe. 



\,^* ^/ 

Suitable shape for sole of child's shoe. 



middle line ; the right and left are told only from the arrangement of the 
buttons, and are frequently worn interchangeably. Now, the foot has no 
such median line on each side of which the parts are equally disposed ; 
and its two edges are very different, as a glance at the soles of this one- 
and-a-half-year-old child's feet will show (Case 44, Fig. 39). 

We must note especially that the phalanges of the great toe do not naturally point 
towards the outer border of the foot : such a position, common as it is in the adult, must be 
considered as an acquired deformity which started, in all probability, with the first pair of 
leather boots. 



140 PEDIATRICS. 

I will now show you how contrary to all anatomical rules are the shoes 
which are usually sold for young children. Dr. Dane, to whom I am in- 
debted for all these valuable suggestions concerning children's feet and shoes, 
has made a tracing of this child's foot to show how the lines of the sole 
ought to run, in order to be adapted to the anatomical conditions. The 
dotted line around the left-hand tracing shows the shape of the shoe that was 
provided for the child's foot at the shoe-store. 

That this matter of forcing the first toe out of its normal position may 
bring with it very serious consequences is easily shown : as it inclines against 
the terminal phalanx of the second toe, it often crowds it backward, and 
finally makes it the distressing ^' hammer toe," which may even require a 
surgical operation for its relief. On the inside of the foot, as soon as the 
axis of the first toe is bent, we begin to find a bulging out of the metatarso- 
phalangeal joint, which in later years, fostered by pair after pair of tight and 
ill-fitting boots, is capable of giving the most exquisite pain. Still more 
subtle in its working than this is the trouble that often comes from disabling 
the great toe from performing its full function. The elasticity of our step 
depends largely upon our power to press down firmly with the great toe and 
then raise the weight of the body over it as a support ; when this is lost by 
crippling the toe with ill-shaped boots, the muscles not only of the first digit 
but of many adjacent groups begin to atrophy. This soon leaves the inter- 
nal arch of the foot without sufficient support, and the long series of woes 
incident to '^ flat-foot" is started upon. Therefore, for one and all of these 
reasons, let us demand that children's feet shall have at least the chance to 
develop properly in well-fitting anatomical shoes. 

SLEEP. — Infants and young children vary much as to the amount of 
sleep which they need and take during the day. At first they sleep almost 
continuously, especially if they happen to be somewhat premature. In a 
few weeks, however, they begin to have regular periods of rest, consisting of 
several hours' sleep, at first twice in the day, and later once. The more sleep 
they can be induced to take in the twenty-four hours, the better. As they 
grow older the amount of sleep which they take grows less, but in the first 
four or five years of life it is well to try to induce the child to rest quietly 
on its bed for at least an hour during the day. 

\^;^HEN TO GO OUT OF THE HOUSE.— If the infant happens to 
be born in the winter months and the weather is at all severe, it is better to 
keep it in a well-ventilated nursery, such as I have already described, than 
to run the risk of its vitality being lowered by exposure to cold. I believe 
that infants in our Northern climate are exposed to cold far more than they 
ought to be, and that they need fresh, warm, dry air, rather than the cold 
and often damp air of our winter months. When they are born in a milder 
climate, or at a warmer season of the year, they can after the first few weeks 
be taken out in their carriages often twice a day. When the infant is five or 
six months old I am in the habit of giving the following directions to the 
mothfer as to when she shall send it out. I explain to her that it makes as 



HYGIENE OF THE NURSERY. 141 

much diiference whether the air is damp or dry, and what the rate of the 
wind may happen to be, as does the number of degrees indicated on the ther- 
mometer. If the sun is shining, the air dry, and there is no wind, the infant 
can without harm go out for an hour in the middle of the day even at a 
temperature of —6.6'' to —3.8° C. (20° to 25° F.). Where, on the contrary, 
the air is damp, or the rate of the wind is great, it is better for the infant to 
remain in its nursery, and, at any rate, not to go out, if the temperature is 
below 0° C. (32° F.). The practice of allowing the infant to sleep in the 
open air in its carriage in every kind of weather is, I believe, a bad one; 
but on the days when it is proper for it to go out, such as I have already 
described, it can without harm sleep in the open air. The nurse should be 
directed to protect the infant's eyes from the direct rays of the sun, and 
not to allow a strong wind to blow in its face. 

Where the weather has been too severe or damp for the infant to go out 
in its carriage for some time, it is advisable to have it dressed warmly and 
wheeled up and down in its nursery with the window open for fifteen or 
twenty minutes. To avoid too much draught, blankets can be placed over 
the cracks of the doors and the open fireplace while the infant is breathing 
the fresh air. The room being far above the ground, the dampness is 
avoided, and even a considerable velocity of the wind outside the house will 
in this way be unable to affect the air of the room, and will not make too 
strong a draught. 

Not only should an injudicious administration of cold air be avoided, but 
extreme care also should be taken in hot weather that the child is not exposed 
to too great direct heat from the sun, and it should never be kept in a hot 
atmosphere where currents of fresh air cannot have access. 

NURSERY-MAIDS. — The idea that the child should be taken care of 
by an old, experienced nurse is a vicious one. The experience of nurses, as a 
rule, is that of ignorance rather than of intelligence. Every mother, as she 
is presumably more intelligent than the nurse whom she employs, and is 
surely more interested in the welfare of her child, should personally super- 
vise and unhesitatingly investigate all that the nurse does to the child. The 
nurse's ideas as to what is needed for the child's hygienic surroundings, food, 
and clothing can well be dispensed with. The mother, learning from the 
physician what is best for her child, should give her directions to the nurse 
and see that these directions are strictly carried out. A nurse between the 
ages of thirty and forty is preferable to one who is younger or older. 8he 
should be neat, healthy, strong, cheerful, gentle, and patient. She shouki be 
willing to refer small details of the nursery routine to the mother, as well 
as those whidi appear of greater importance. The chief attributes of a good 
child's nurse, in my opinion, are a desire to obey implicitly the orders which 
she receives from her mistress, and a temperament in harmony with the sen- 
sitive nervous organization of her charge. 

MOUTH. — I shall ask you to join me in entering a protest against the 
way in which the nurse, and in fact almost every one who comes near the 



142 PEDIATRICS. 

infant, put their fingers into its mouth on all occasions. It would seem as 
though the infant's mouth was considered by those who ought to know better 
as something which was especially made to be felt. Infants are much more 
likely to have various diseases in their mouths than are adults, and probably 
one reason for this is that dirt of all kinds is constantly being introduced 
into them. The fingers should always be thoroughly washed before enter- 
ing the infant's mouth, and yet unwashed fingers are continually feeling the 
baby's gums to ascertain if a tooth can be found. 

The nurse should be instructed that she is never to kiss the infant on its 
mouth, or allow any one else to. The germs of disease can well be transmitted 
in this way. It is partly through ignorance of its doing harm, and partly 
through timidity on the part of the mother in prohibiting it, that a stop is not 
at once put to this bad habit of nurses and friends, and it is the physician's duty 
to warn mothers on this apparently trivial but really important question. 

In a later lecture, when speaking of tuberculosis (Case 263, page 603), 
I shall report to you a particular instance where the child was, in all prob- 
ability, infected by the breath of its nurse. 

SCHOOL. — I have not a great deal to say about schools. I think, how- 
ever, that much ignorance of the child's nervous organization is shown, by 
those who should best know how to care for it, at a period of life when its 
hygienic surroundings, both mental and physical, are extremely important. 
No one system is good for all children. I am sure that I have seen the 
kindergarten system do harm to a number of children, although it seems to 
suit others. Each child should be gauged for itself, and not be forced into 
any general system, even if that system has proved to be good for the many. 
No time is lost, in my opinion, in sending children to school at a somewhat 
later age than is usually supposed to be necessary. I am continually having 
to take little children out of school who are fretful and have loss of appetite. 
Neither parents nor teacher seem to appreciate that the little, actively growing 
brain is overtaxed by too great stimulation and is protesting against such 
treatment by these general symptoms. Many a child is being dosed with 
tonics who merely needs rest from school. The parents should keep the most 
rigid supervision over their children while at school, and notice from their be- 
havior whether they are mentally tired. This supervision should not be left 
to the teachers alone, however interested they may be in their little pupils. 
It seems hardly necessary to state that the school-room should be well ven- 
tilated, and that at stated intervals during the school hours the windows 
should be thrown open and the atmosphere of the room completely changed. 
This should not, however, be done with the children in the room. Atten- 
tion should be paid not only to what the children eat at lunch, but to how 
and where the lunch is eaten. A child really needs nothing but dry bread 
between its meals, so far as its nutrition and digestion are concerned. 

DEFECTS OP POSTURE.— How can we better appreciate the im- 
portance of following nature as closely as possible in its methods of de- 
veloping young human beings so as to perfect their various functions to the 



HYGIENE OF THE NURSERY. 143 

fullest extent, than by examining carefully this group of malformed children 
which I have brought here to show you? (Cases 45, 46, 47, 48, and 49.) 

Back. — The extreme flexibility and slow development of the spine 
clearly point out to us that nature intends to leave its function in abeyance 
and bring it into use slowly. If the young infant is allowed to sit or stand 
at too early an age, the superincumbent weight of the large head tends at 
once to exaggerate the physiological curves of the spine to a point where they 
may become pathological. As I have already told you in my lecture on 
Development, during the first year of life the strength of the spinal column 
is slowly increasing. Not before the seventh or eighth month has it ac- 
quired sufficient rigidity to warrant the child's being allowed to sit up. 
Artificial methods, therefore, of making the young infant assume a sitting 
posture at a period of development when the spine should be comparatively 
straight should be deprecated. I have met with numerous instances where 
both parents and nurses were anxious to have the infants, at a very early 
age, sit for quite a long time strapped in small chairs. In like manner the 
same infants were encouraged to stand and walk long before the apparatus 
for locomotion was ready for use. We may ask, how many of these indi- 
viduals developed a spinal curvature in later childhood ? Possibly the risk 
in a perfectly healthy child may be small. We often, however, in early 
infancy, cannot determine which individual may become rhachitic, and 
where rhachitis is present the tendency to abnormal curvature is well knoAvn. 

We should, then, in our advice as to the proper physical management 
of the early years of life, be guided by our knowledge of the normal 
average development. Free play for the infant's legs, when lying on its 
back in bed, should be a point to be noticed and considered, since we know 
that pressing down the legs causes strain and curvature in the lower spine. 
Knowing the great lateral flexibility of the infant's spine, Ave should advise 
the nurse not to hold the infant continually on one side. Symmetry of de- 
velopment and free opportunity for natural movement should be our aim in 
the management of the infant from the very earliest period of its existence. 
Our knowledge of the great flexibility of the growing spine provides us at 
once with a most valuable means for treating lateral curvature in childhood, 
and we are continually seeing the benefit of encouraging the promotion of 
elasticity by moderate pressure and bending. A case Avhich is noAV under 
observation in my service at the Infants' Hospital beautifully illustrates the 
truth of what has just been said. 

A feeble, rhachitic child (Case 45), nineteen months old, was presented for treatment 
with a marked lateral curvature in the dorsal region, the convexity being towards the right, 
combined with decided rotation, following the type of the worst adult cases. 

The condition seemed to be purely the result of habit, the patient having been made, 
when very young, to sit up beyond the limit of endurance of the still undeveloped bones 
and ligaments. The treatment instituted by Dr. E. W. Lovett, who took charge of the 
case,, was based entirely on the elasticity of the spine, and consisted simply of manipulation 
and recumbency, resulting in a very great degree of improvement both as to the curvature 
and the twistinsf. 



144 



PEDIATRICS. 



Dr. Lovett also tells me that in the surgical out-patient clinic at the 
Children's Hospital the improper treatment of the young subject's spine, as 
in infants, for instance, where they are carried altogether on one side, is 
well recognized as an important factor in the etiology of rotary lateral 
curvature. I have seen in this clinic a number of examples of this class, 
and have been much impressed with the important relation which anatomical 
knowledge bears to clinical prophylaxis, diagnosis, and treatment. 

If you will bear in mind what I told you in speaking of the ossification 
of the different parts of the spinal column, you will readily understand that 
so long as an infant can be made happy in the prone position, whether in its 
nursery or in its carriage, it will be better for it to be kept in this position, 
always protecting the eyes when out in the open air from the strong light, 
and the face from the wind. During the first year when it begins to sit up 
in its carriage its back should be carefully supported by a pillow. 

Case 46. 




Posterior spinal curvature from sitting too soon. 



I have here to show you an infant (Case 46) who is a fitting example of the harm 
which can he done by encouraging children to sit up before their spinal columns are suffi- 
ciently strong. This infant, six months old, has been made to sit in a chair for hours at a 
time, strapped in a position which allowed it to use its arms, but such as to render it im- 
possible to fall back and rest itself. You see the exaggerated curve of its back, which cor- 
responds to that which would be seen normally at birth. Such a curve I have already 
shown you in Diagram II., Curve 1. If this infant had not been made to sit until it had 
developed sufficiently to acquire the physiological curve (Diagram II., Curve 2), it would 
not at this age show any spinal curvature. It has, however, through improper treatment 
reacquired the posterior curvature (Diagram II., Curve 1) of the early hours of life. 



HYGIENE OF THE NURSERY. 145 

As the child grows older^ weak undeveloped muscles have a tendency to 
allow lateral and posterior curvatures to be produced. Habit, of course, has 
much to do with these faulty positions of later childhood. 

Case 47. 





Lateral curvature of the spine. Child four and one-half years old. 

This little girl (Case 47), aged four and one-half years, shows a lateral curvature, not 
from disease of the spine, but one which is usually explained as a result of superincumbent 
weight coming upon muscles which are unable to support it properly. 

You will notice, on looking at her from behind, the curve which the line of the spinal 
column takes to the right in the dorsal region, so different from the straight line of the 
normally developed boy which I showed you in my lecture on Normal Development (Di- 
vision II., Lecture IV., page 124, Case 38). On looking at this same child in front, you will 
notice how the right shoulder is higher than the left and how the whole thorax is in a dis- 
torted position. These deformities are always more readily recognized by looking at the 
child in front and preferably across the room, as the outline of the chest and hips is nuich 
more clearly defined on the anterior aspect of the body than on the posterior. Posteriorly 
you will in cases even of the slightest lateral curvature at once notice the difference in the 
level of the tips of the scapulae. This child stoops, and has what is commonly called 
round shoulders. 

This should teach you that in any case of round shoulders lateral 
curvature should be thought of and carefully eliminated. 

10 



146 



PEDIATRICS. 



Faulty attitudes in sitting and standing play a great role in producing 
these curvatures. We must, however, acknowledge that such spinal curva- 
tures have been differently explained on the ground that they are the result 
of a lack of development of all the tissues upon one side of the spine. Other 
explanations have also been given ; but in certain individual cases it is impos- 
sible to formulate any reasonable cause for the curvature. 

Legs. — At birth the infant's legs are curved rather than straight, as I 
have already described to you (Lecture lY., page 118), when I showed you the 
infant skeletons at birth and at nineteen months. The natural tendency of 
the growth of the legs is to become straight, but if the child is encouraged 
to stand and walk too soon, especially if the bones have not been properly 
nourished, the weight of the head and trunk becomes too great to be sup- 
ported by the legs, which curve outward in the form of an ellipse, a condition 

which is called '^ bow-legsJ^ 

Case 48. 




Bow-legs. Child three and one-half years old. 

This little boy (Case 48), three and one-half years old, has, as I learn, been encouraged 
by his parents to stand and walk before he was a year old. 

His nourishment has also been rather imperfect, but he is not rhachitic. You see as 
the result of this combination of circumstances a decided bowing of both legs. He is being 
treated in my ward for facial eczema, which accounts for his rather startling head-gear. I 
shall describe him as a case of eczema in a later lecture. 



HYGIENE OF THE NURSERY. 



147 



Case 49. 



The deformity called " knock-knee/' in which the leg at the knee bends 
in rather than bows out^ may occur from simple weakness, but is so rare 
except when rhachitis is present that it is better 
to speak of it in connection with that disease. 

Finally, I should like you to examine carefully 
this girl's back (Case 49). 

She is fourteen years old, and presents, as you see, a 
typical case of bow-legs and of lateral curvature. 

These conditions are not the representatives of disease of 
the bone existing now, but are the result of improper nu- 
trition causing the bones to become softened (rhachitic) and 
easily bent. They are also the outcome of lack of care to 
correct, by proper gymnastic exercises, weak muscles and 
bad positions of the trunk. TVhen we consider that such 
conditions as we see so marked in this girl could have been 
obviated by proper treatment at an earlier period of child- 
hood, when they were beginning, we can readily understand 
the importance of carefal medical supervision in preventing 
the acquisition of various deformities. 

VACCINATION.— It is now pretty well ac- 
cepted throughout the world that the introduction 
of the vaccine virus into the circulation protects 
the individual from variola. The physician in 
general practice, however, is so often questioned as 
to the advantages in contrast with the dangers of 
vaccination, that it is particularly advisable in 
regard to infants and children to know a few facts, 
especially concerning primary inoculations. Ac- 
cording to the careful investigations of McCollom 
on the history of variola and vaccination, compul- 
sory vaccination was suspended in Zurich, Switzer- 
land, in obedience to popular clamor, in 1883. The 
deaths from variola, out of one thousand deaths 

from all causes, for the previous two. years and that year had been, — in 
1881, 7; m 1882, 0; and in 1883, 8. After compulsory vaccination had 
been done away with, the deaths rose in 1884 to 11.45, in 1885 to 52, 
and in the first eight months of 1886 to 85 per 1000. 

In this connection it is of interest to note that during the epidemic of 
variola in Prague in 1888, 76.57 per cent, of the unvaccinated died, while 
only 10.58 per cent, of the vaccinated succumbed to the disease. 

In Boston from 1721 to 1792, a period of seventy-one years, there were 
three very severe and fatal epidemics of variola, or one in about every twenty- 
three years. From 1792 to 1892, a period of one hundred years, there 
had been only one severe epidemic of this disease, and even this could not 
be compared in severity with those in the last century. The protective power 
of vaccination is the only possible explanation of this comparative immu- 




.l:^ 



Spinal curvature and bow- 
legs. Girl aged fourteen years. 
Rhachitis and lack of care in 
earlier childhood. 



148 PEDIATRICS. 

nity from variola during the last hundred years. In the past ten years the 
percentage of deaths among the un vaccinated at the Boston Small-Pox Hos- 
pital has been 75, while that of the vaccinated has been only 3 per cent. In 
the past twelve years no person who has been successfully vaccinated within 
five years has died of variola, and those who have been attacked by variola 
have had the disease in a very mild form. 

Dr. Barry, in his report of an epidemic of variola at Sheffield, England, 
during 1887 and 1888, gives a very clear idea of the relative frequency of 
deaths occurring in the vaccinated and in the unvaccinated. I have arranged 
a table (Table 32 a) which illustrates his results very well, and shows the per- 
centages of those who, living in houses invaded by variola, were attacked by 
the disease, and also how many of these died. It also gives the percentages 
for all ages, for under ten years and for over ten years. 





TABLE 32 a. 








Individuals living in Houses invaded hy Variola. 






(1) 


(2) 


(3) 




All Ages. 


Over 10 Years. 


Under 10 Years. 


Vaccinated. 


r Attacked . . 23.0 per cent. 
iDied .... 1.1 


28.1 percent. 
1.4 


7.8 percent. 
0.1 


Unvaccinated. 


(Attacked . . 75.0 " 
I Died .... 37.2 " 


68.0 
37.1 " 


89.9 
38.1 " 



The low percentage of children as shown in column (3) is very striking 
in comparison with column (2), which represents older individuals and enun- 
ciates the importance of revaccination. A glance at the table at once im- 
presses upon us the significance of the difference in the number of deaths 
between the vaccinated and the unvaccinated. We can hardly imagine any 
other explanation for this great difference in the mortality rate than the sup- 
position that the vaccine virus is highly protective against variola. Still 
more striking are the actual figures recorded as representing very large num- 
bers of cases of variola. These figures show that among the vaccinated, nine- 
teen individuals out of twenty recovered, while of the unvaccinated, fifty 
individuals out of one hundred died. It is not held by the advocates of 
vaccination that one vaccination will protect for a lifetime. On the contrary, 
revaccination is just as important as the primary operation. One attack of 
variola does not always protect an individual from a second invasion, and 
more should not be expected from the operation of vaccination. 

Dr. Josef K5r5si, Director of the Buda-Pesth Statistical Bureau, has lately 
published the statistics of 112,000 observations made with reference to the 
deleterious after-effects of vaccination. As a result of these observations, 
the author concludes that, even if any slight increase of mortality can be 
charged to vaccination in certain specified diseases, there should be placed to 
its credit a saving of life at least three hundred times as great. Kordsi 
stands at the head of living statistical authorities upon vaccination ; hence 
his conclusions are entitled to great respect. He attaches to vaccination a 
greater preventive power than to any other known means or appliance in the 
whole field of medicine. 



HYGIENE OF THE NURSERY. 149 

Variola has been communicated to the cow by direct implantation of the 
virus. The efforts to accomplish this were numerous and at first unsatis- 
factory. The first successful inoculation of this nature was at Berlin, in 
1801. Since then many observations have been made in this direction, and 
the conclusions of those who have carefully studied the subject and are there- 
fore qualified to judge are that : 

1. Variola is inoculable on the bovine species when the method of oper- 
ation is good and when the virus is taken at the proper time. 

2. Inoculation of the calf with variola forms a valuable source, in a new 
direction, for obtaining animal vaccine. This is of great practical value not 
only for the vaccine institutions of Europe, but also for those of warmer 
climates, where variola is frequently endemic and where vaccine rapidly 
deteriorates. 

3. Variola inoculated on the calf is transformed after several transmis- 
sions into vaccine by its passage through this animal. Dr. Fischer, Direc- 
tor of the Vaccine Institute at Karlsruhe, in Germany, performed at about 
the time when K5rosi was investigating this subject a series of similar 
experiments, and he arrived at practically the same conclusions. These 
experiments, according to McCollom, refute the argument of ignorant theo- 
rizers, that the vaccine disease cannot protect against variola because there 
is no connection between these two diseases. Finally, I am authorized by 
Dr. John H. McCollom, the city physician of Boston, to state that no death 
from variola has occurred during the last ten years here in Boston of a child 
who had been vaccinated before it was five years old. With these facts 
before us, I shall not discuss further the merits and demerits of vaccination, 
but shall take it for granted that it is well to vaccinate the young infant. 
The time at which this should be done is, I think, of considerable importance. 
The infant should be vaccinated early, before it begins to be exposed to the 
danger of contagion from sources outside of its home. We must, however, 
remember how low is its vitality at birth, and how readily this vitality is 
affected by what would be considered trifling conditions for the older child 
or for the adult. A time should be chosen when the infant is not subject 
to the other disturbing conditions which naturally arise in the first two years 
of life, such as weaning and the irritation of the dental periods. If it is 
found necessary to vaccinate the infant after the sixth or seventh month, or 
before the twentieth, it should be done in an interdental rather than in a 
dental period, and not at the time when its food is being changed, or when 
it is suffering from either slight catarrhal conditions or some definite disease. 
I prefer to vaccinate the infant when it is four or five months old, — that 
is, just before the period when the first tooth appears. At tliis age it has 
usually become accustomed to its food, its digestion is in equilibrium, and its 
vitality is much above what it was in the early weeks of its life. By the 
fifth month also it will usually have developed the outward symptoms of 
syphilis if it has inherited that disease from its parents. You will thus not 
be so likely to be blamed for having inoculated with something besides the 



150 PEDIATRICS. 

vaccine virus, which might happen if after vaccinating in the early weeks of 
life a syphilitic efflorescence should appear. The vaccine virus can be intro- 
duced into any part of the body through the skin, and according to the fancy 
of the physician or parents. Girl infants can be vaccinated just below the 
knee on the outer side of the leg, so as to avoid having a scar on the arm, to 
which women usually object. I am accustomed to vaccinate boys on the outer 
side of the upper arm. Whether the vaccination is performed upon the leg 
or the arm, we should first inquire if the person who is to take care of the 
infant is right-handed or left-handed. If the nurse, for instance, is right- 
handed, she will naturally hold the infant on her left arm, and in this case, 
the infant's right arm being towards the nurse, it is better for the vaccina- 
tion to be on the left arm. The process should be reversed where the nurse 
is left-handed, and in this case, for the same reason, it is better to vaccinate 
on the right arm or leg. The form of virus which I have been accustomed 
to use, and which I consider the best, is taken from cows rather than from 
human beings. It should be very carefully prepared by those who have 
made a scientific study of the subject, and, if possible, on farms which are 
under State supervision. 

I shall now show you the details of vaccination such as I have found in 
my practice to be the best. It has been pretty well proved by careful ob- 
servation of large numbers of primary vaccinations that those who in later 
life contract variola have the disease in a less severe form where in their 
primary vaccinations they have been inoculated in three places at once 
rather than in two, and in two places at once rather than in one. The gen- 
eral constitutional disturbance also does not appear to be greater where the 
inoculation has been in two or three places rather than in one. The evi- 
dence therefore seems to be in favor of inoculating in two or three places 
in primary vaccinations. A very small surface is amply sufficient for the 
proper introduction of the virus. This pointed ivory quill (Plate IV.) is 
charged, as you see, with virus, and can be used directly for removing the 
epithelium, for exposing the smaller blood-vessels, and for introducing the 
virus. I prefer not to use any more instruments than possible, in order to 
avoid the possible introduction of some foreign substance which might inter- 
fere with the natural course of the vaccine virus and cause unnecessary 
inflammation. 

I will now vaccinate before you this infant (Case 50), a girl, four and one-half months 
old, and I have chosen as the place for the introduction of the virus this point just below 
the knee on the left leg. I first wash my hands very thoroughly. I then wet the 
end of a freshly-boiled clean towel in water that has just been boiled. The skin is then 
thoroughly rubbed with the hot water, and not dried. This procedure accomplishes two 
purposes. The first is to remove all dirt or extraneous matter from the spot where we 
are about to expose the blood-vessels, and thus lessen the danger of septic absorption. 
The second is to remove the external layer of the epithelium, which has been softened 
by the hot water, and thus render the subsequent scratching less painful and shorter in 
its duration. I now make a series of short scratches about one-half centimetre (about 
one-fourth inch) long, four or five in number, and in two sets, one crossing the other, until 



At '6^'nv, 



TV. T- 



Vaccina iiOT' ocrafCf 



-AD'-'uay. 



At lO'^Da 



At!2'.!'Da> 







Scaraf I year 



'894byJ.B.Li| 



Scar d*. f'l years 



HYGIENE OF THE NURSERY. 151 

the epithelium is sufficiently removed to show that the blood-vessels are exposed, but 
not to a degree that bleeding should take place, for in the latter case the virus may be pre- 
vented from gaining an introduction to the general circulation. (Plate IV.) The point 
of the quill should now be dipped into water which has been freshly boiled (sterilized). The 
flat part of the quill which is charged with the virus is then thoroughly rubbed into the 
wound. The skin should be protected for four or five minutes from contact with anything ; 
after this the infant can be bathed or go out as usual. In some cases I have waited until 
the scratch has dried, and then have covered it with a small piece of aseptic cotton which I 
sealed at the edges with collodion. After three or four days this cotton can be removed, 
and, unless the subsequent lesion is broken, this measure is an additional safeguard against 
infection from extraneous matter in the first few days. 

Having now shown you the details of the vaccination of this infant, I 
will also show you a number of cases at different periods of the evolution 
of the vaccine virus. (Plate TV. shows the different stages as they occurred 
in one carefully observed case seen by the artist and myself every day.) 

This infant (Case 51) was v&ccmsited Jive days ago. Nothing especial was noticed until 
yesterday, when a little red papule appeared over the side of the vaccination, and to-day 
you see at the end of the vaccination scratch a round clear vesicle, while at the other end 
there happens to be left a little brown crust. (Plate TV.) 

This next child (Case 52) was vaccinated eight days ago. You see an irregular-shaped 
lesion about ^ cm. (^ inch) long, and 1 cm. (| inch) wide, somewhat depressed in the middle, 
and with a clear vesicular border. (Plate TV.) 

Here is a case (Case 53) which was vaccinated ten days ago. You see that the lesion 
of the last case (Case 52) has now increased in length to 2 cm. (|- inch) long, and to a little 
over 1 cm. (|- inch) wide, but we now have an erythematous condition of the skin forming 
an areola with a diameter of about 2 cm. (| inch), in the middle of which is the lesion just 
described. This areola is a light shade of red, and on its outer border are, as you see, 
irregularly distributed little light red maculae. (Plate IV.) 

This next child (Case 54) was vaccinated twelve days ago, and you see very nearly the 
same appearances as have occurred in the last case, except that the areola is very much more 
intense in its red color, and has grown to the size of a circle 3 cm. (IJ inches) in diameter. 
Some of the little maculae have become vesicles. (Plate IV.) 

This child (Case 55) was vaccinated sixteen days ago, and in place of the vesicular 
lesion with its depressed centre you see that a crust has formed with a narrow line of redness 
around it, and on the outer border of this areola the redness is gradually becoming fainter 
and shading ofi* into the normal skin. (Plate IV.) 

Pinally, here is a child that was vaccinated nineteen days ago (Case 56). The crust 
is smaller than in the one which I have just shown you at sixteen days, the redness has 
disappeared, and where the areola was most pronounced there is slight desquamation. 
(Plate IV.) 

This child and its nurse (Cases 57 and 58) present one of the usual appearances of the 
vaccination scar at one year and twenty-one years. (Plate IV.) 

Of course every case of vaccination does not present exactly the same 
appearances. The lesions may differ in shape and size, and one individual 
may be affected more intensely by the virus than another ; one may have 
accompanying severe constitutional symptoms and another have none. The 
chain of lymphatics may be affected as far as the axilla or the groin. 

As a rule, the following description represents pretty well the usual 
course of the disease. After the vaccination, the skin shows nothing new 
until the third, fourth, or even fifth day, when a small red point appears. 
This soon becomes a papule ; by the next day a vesicle is developed ; about 



152 PEDIATRICS. 

the sixth day this vesicle usually becomes umbilicated, and is surrounded by 
a faint red zone. By the eighth day the vesicle is fully developed, and by 
the ninth day the red zone increases rapidly and the vesicle soon becomes a 
pustule. By the eleventh or twelfth day a crust is formed, and this crust 
falls from about the fourteenth to the twenty-first day, in some cases an ulcer 
being left which heals by another crust being formed, in others the skin 
remaining intact. From the eighth to the twelfth day there may be a slight 
amount of fever and coated tongue, with some loss of appetite, and the 
glands of the axilla or groin may become enlarged and tender. The scar, 
though perhaps not typical, can usually be recognized by its small depres- 
sions (pits) and its location. 

In a certain number of cases, instead of this regular progression of the 
vaccine disease with its characteristic development in a single lesion of the 
skin, the virus appears to give rise to the original disease cow-pox (vaccinia). 
Vaccinia is characterized by the appearance of papules, vesicles, and pustules 
of different sizes in different parts of the body and limbs as well as on the 
face, and running a definite course. I happen to have a case of this kind to 
show you (Case 59). 

This little girl, two years old, was vaccinated ten days ago. You see the characteristic 
lesion of vaccination on the arm. You will notice, however, on the side of the nose, on 
the forehead, behind one of the ears, and on the chest, a number of papules, umbilicated 
vesicles, and a few pustules. These lesions evidently represent something more than the 
usual course of a vaccination. It is, in fact, a case of vaccinia (cow-pox). The consti- 
tutional symptoms are not pronounced in this case, and there is no doubt that the child will 
make a rapid recovery. 

Vaccinia is in my experience a rare disease ; its lesions when following 
vaccination appear at about the fifth day after the inoculation. At the end 
of four days, however, minute vesicles can be seen with a magnifying glass. 

In some cases, instead of the healing of the scratch in a few days, or the 
formation of the vesicle of a successful vaccination, irregular excrescences 
of a fungus-like character may appear. These in all probability have no 
connection with the true vaccine virus, and are not protective. In addition 
to the rather rare cases of vaccinia to which I have just alluded, various 
efflorescences at times appear on the skin, not only in the neighborhood of 
the vaccination lesion, but also in other parts of the body. They may be 
present on the fourth or fifth day, or even later, in the second week, and are 
probably caused by some reflex connection with the vaccination lesion. They 
vary considerably in form, but are usually represented by a multiple or 
papular erythema or an urticaria. It should be remembered, where an un- 
vaccinated child has been exposed to variola, that if you vaccinate it within 
forty-eight hours it will probably be protected, and if within five or six days 
the variola poison will be so modified as to produce only a mild form of the 
disease. Following the advice of Dr. McCollom, if such a case were pre- 
sented to me I should vaccinate the child in two places. I should then wait 
for forty-eight hours and repeat the vaccination in a third place. 



DIVISION IV. 

FEEDING. 



LKCTURE VI. 

THE GENERAL PRINCIPLES UNDERLYING ALL METHODS OF 
INFANT FEEDING. 

Just as the highest aim of medical art should be directed to the province 
of preventive medicine, so the highest and most practical branch of pre- 
ventive medicine should consist of the study of the best means for starting 
young human beings in life. They should be preserved from the perils 
which surround the early hours of their existence, and be given strength 
and vigor to resist the attacks which must inevitably be made on their 
vitality, and which are greater and more dangerous in inverse proportion to 
their age. With these objects in view, the preventive medicine of early life 
becomes pre-eminently the intelligent management of the nutriment which 
enables young human beings to breathe and grow and live. In fact, it is 
a proper or an improper nutriment which makes or mars the perfection of 
the coming generations. The feeding of infants is, then, the subject of all 
others which should interest and incite to research all who are working in 
the domain of pediatrics. The subject is a great one, and is worthy of the 
attention of the greatest minds of the age. The responsibility of discussing 
so serious a question is a grave one. It should be taken up carefully. It 
should be dealt with broadly. AVe must acknowledge for the present that in 
the status of feeding, as it has existed up to the last few years, the average 
human breast-fed infant was more likely to live, other conditions being 
the same, than the infant which was fed by any other method. But we nuist 
remember that the latest investigations of this subject show very ck^arly that 
it is not human milk as a Avhole which is pre-eminently good, but that it is 
a varied combination of the different elements of tlie milk which makes it 
the best food during the first year of life. It is our province to study and 
make use of these elements of the food, which Avere once somewhat myste- 
rious, but which are now rapidly becoming known through the work of 

patient and careful investigators. 

153 



154 PEDIATRICS. 

In reviewing the immense amount of literature which, has accumulated 
on the subject of feeding, we find that the superiority of human milk to all 
other kinds of infant food in the early months of life is acknowledged so 
generally that it has become an axiom. On the other hand, the opinions 
expressed regarding artificial feeding in the past are so diverse and so 
opposed to one another that it is evident that much which has in former 
years been taught must be unlearned, or rather admitted to be untrue, before 
we can expect to make any decided progress in this most difficult subject. 

In our endeavor to copy nature we may hope that, as our knowledge 
increases, more and more light will be thrown upon those points which are 
now obscured by ignorance. It is, indeed, of the first importance that we 
should recognize our ignorance, and, watching every advance which science 
is making in this subject, be ready to sweep aside preconceived ideas which 
do not rest upon established facts, and thus by wise iconoclasm build our 
knowledge on a surer basis. 

The great number of artificial foods used by physicians according to the 
fashion of the day only proves that artificial feeding has never arrived at that 
state of perfection where it could compete with human breast feeding. The 
difficulty in approaching the study of the subject has been that physicians as 
a class have regarded it too purely from a clinical stand-point. We know, 
for instance, how easily we may be misled by the apparently good effects of a 
medicament where perhaps on further investigation, or in the light of some 
new discovery, we learn that the improvement in the case was due not to 
the drug, but rather to circumstances entirely apart from it. The same 
rule applies equally well to the case of many foods and methods of feeding. 
To state concisely what I have already referred to, we should, in study- 
ing the form of nutriment which shall be suitable for an especial period 
of life, manifestly be guided by what nature has taught us throughout 
many ages. The researches of science at present, especially in the subject 
of infant feeding, are wisely directed towards learning to read the truths 
which nature presents to us. Great progress has been made in reading 
these truths. What we are also endeavoring to do is to copy them, and in 
regard to human milk a great advance has been made in our knowledge as 
to what we are to copy from it. 

The feeding problem is one which is hedged about with many difficul- 
ties on account of the great diversity of individual circumstances and idio- 
syncrasies. Certain infants thrive on peculiar mixtures which are not 
adapted to infants as a class. Many will not thrive on that food which 
nature has provided for them, and the well-being of an infant will depend 
much upon the circumstances by which it is surrounded, such as affluence or 
poverty, country or city life. The constituents of the nutriment which nature 
has provided for the offspring of all mammals in the early period of their 
existence is essentially animal and never vegetable. Human beings in the 
first twelve months of life are carnivora. It is therefore evident that an 
animal food, entirely and freshly derived from animal and not vegetable 



FEEDING. 155 

sources, has been proved to be the nutriment on which the greatest number 
of human beings live and the least number die. 

MAMMARY GLAND. — In regard to the early months of life, a 
knowledge of the changes which take place in the mammary gland' from 
many causes is of vital importance and must* be kept in view. The methods 
of modifying the milk in the mammary gland, however limited in their 
scope, should be carefully investigated and adapted to the individual infant 
according to its age and size and general physical condition. The mam- 
mary gland, in its perfect state, uninfluenced by disease or nervous disturb- 
ance, or by the improper living of its owner, is a beautifully adapted piece 
of mechanism constructed for the elaboration and secretion of an animal 
food. When in equilibrium it represents the highest type of a living machine 
adapted for a special purpose, — mechanically, physiologically, and economi- 
cally. When from any cause this sensitive machinery is thown out of 
equilibrium, its product is at once changed, sometimes slightly, but again to 
such an extent that the most disastrous consequences may follow when it is 
taken by the young consumer. The breasts of all mammals are elaborators 
and producers. They are not storehouses for preserving sustenance until it 
is needed. They are delicately constructed mills, turning out, when demand 
is made for it, a product which has been directly formed within their walls 
from material which has been brought through their portals from various 
parts of the economy. The breast is a compound racemose gland, lined 
with glandular epithelium, which forms sugar, fat, and proteids, and these 
are mixed with water and salts from the blood. The epithelial cells are so 
finely organized, and so sensitive with their minute nerve connections, that 
changes of atmosphere, changes in food, the emotions, fatigue, sickness, the 
catamenia, pregnancy, and many other influences, throw their mechanism 
out of equilibrium most readily, and change essentially the proportions of 
their finished product. Then again this delicate mechanism adapts itself 
to the quantity of its product, elaborating a smaller or a greater supply, 
according to the demand actually made upon it by the consumer. The 
same breast will either supply the proper amount of milk demanded for 
the requirements of the average age or a greater amount for the same age 
in case of a greater gastric capacity. Again, this machinery is regulated 
as to the time which it takes to produce the average food required for the 
diflerent ages, a shorter interval of feeding being needed for the younger 
infant and a longer one for the older. This fact is made evident by the de- 
cided qualitative changes which result when the gland is called upon to pro- 
duce its product at improper intervals. Thus, a prolonged interval lessens 
the solid constituents in their proportion to the water, while a shortened in- 
terval, by exciting the epithelial cells to frequent work, over-stimulates them, 
with the result of increasing the solids in their proportion to the water. In 
fact, too long intervals produce a product too dilute, while too short inter- 
vals produce a product too concentrated. The analyses of large numbers of 
specimens of human milk at different periods of lactation show us that not 



156 PEDIATRICS. 

only do the constituents vary from month to month, and even from day to 
day, but that this variation takes place as much in the early as in the later 
periods of lactation. We are not warranted, therefore, in assuming that the 
milk grows stronger as its age increases, provided that it still remains in 
normal equilibrium. The mammary gland acts both as a secretory and as 
an excretory organ, so that it cannot be classed as a metabolic tissue in the 
limited meaning which we now attach to these words. Yet the metabolic 
phenomena (Foster) giving rise to the secretion of milk are so marked, so 
distinct, and have so many analogies with the metabolism which we meet in 
adipose tissue, that we must look upon the mamma chiefly as a secretory 
organ. This, however, is only within certain limits, for we know that at 
times foreign elements may be excreted from the gland. This at once 
suggests the interesting question as to when the mammary gland is most 
likely to have what we might call its normal secretory function inter- 
fered with and to assume temporarily the function of an excretory organ. 
This seems to occur both before the gland has attained its equipoise, as 
during the colostrum period, and later when any of the above-mentioned 
influences occur which affect the general mechanism of the gland. In 
these instances we find the colostrum reappearing in the milk. There- 
fore in the beginning of lactation, during lactation when normal metabo- 
lism is interfered with, and as lactation draws to a close, we have analo- 
gous conditions in which the mammary gland instead of being a normal 
secretory organ becomes abnormal and more or less an excretory organ. 
During these periods of abnormal gland excretion we must remember that 
drugs can be eliminated by the milk more freely than when the gland is in 
equipoise. We assume, therefore, that the mamma during that early period 
of lactation, which essentially represents a condition of lack of equipoise, has 
a double function, partly secretory, partly excretory. The greater the excre- 
tory function of the gland is at any time in proportion to the secretory, the 
more abnormal will be the finished product; while the nearer the gland 
approaches to a purely secretory organ, the more perfect and normal will 
be its product. The mechanism of the mammary gland is therefore in its 
most perfect condition after the colostrum period has ceased, and at a time 
when the general organism, both physical and mental, is freed from causes 
detrimental to a perfect metabolism. 

General principles are vital in their importance when we come to study 
the subject of feeding in all its phases, whether the nutriment to be pro- 
vided for the infant is to come directly from its mother, a wet-nurse, or 
an animal, or indirectly from the product of the mammary gland. These 
principles are, (1) That nature throughout all ages has clearly indicated by 
means of natural selection what the source of supply should be ; that is, 
that the mother should during some early period of its life supply food for 
her offspring from her mammary glands. (2) That where, owing to dis- 
ease, over-civilization, or any causes which prevent the offspring from 
receiving its sustenance directly from the maternal mammae, some nutri- 



FEEDING. 157 

ment must be substituted which will correspond as closely as possible to 
the natural food-supply. (3) That this substitution can be obtained most 
exactly through the product of the mammary gland of another woman. 
(4) That^ owing to the strong analogy between human beings and all ani- 
mals which suckle their yoimg, we should in our study of copying good 
human milk make use not only of what we have learned from human 
beings, but also of what is known of lactation as it occm^s in animals. 
This entails acquiiing a knowledge of the investigations and experience 
of those Avho have studied commercially the breeding of animals and their 
food, and the production and modification of their milk. 

I have already explained to you the conditions which are normally 
found in early life from birth to puberty. All these conditions represent- 
ing the various stages of a physiological development must be thoroughly 
understood and remembered if you wish to appreciate the many difficulties 
which are to be dealt with in a practical investigation of infant feeding. 
In my next lecture I shall begin the consideration of feeding during the 
first twelve months of life. This I have designated as " The First Nutritive 
Period:' 



158 PEDIATRICS. 



LKCTTURK VII. 

THE FIRST NUTRITIVE PERIOD. 

I. Maternal Feeding — II. Direct Substitute Feeding — III. Indirect Substi- 
tute Feeding. 

As in my lecture on Development I endeavored to emphasize only those 
facts which would be of practical use to you from a clinical stand-point, so, 
in dealing with the subject of nutrition, I shall not attempt to discuss the 
finer and more intricate questions of physiology and chemistry. While ex- 
pecting to receive great aid from the physiological chemistry of the future, 
we must not allow this fascinating branch of our art prematurely to set aside 
evident clinical truths which for years have emanated from nursery practice 
and have proved to be of great value in it. The nutrition of young human 
beings may be divided into three distinct nutritive periods, corresponding to 
the degree of their development. The first period consists of the first ten or 
twelve months of life. The second period comprises the second and third 
years, and the third period the remaining years of childhood. The science 
of feeding depends almost exclusively, in addition to the general principles of 
which I have already spoken, on the knowledge of what elements of the food 
are required by the growing tissues in these nutritive periods, and also on 
the time when the various digestive functions are ready and able to dispose 
of them. I shall therefore begin with the discussion of the first nutritive 
period, which is essentially the only one where human milk need be consid- 
ered. I have already referred to the marked analogy which exists between 
the nutrition of human beings and other mammals, and the necessity of un- 
derstanding the lactation of animals when we endeavor to explain that of 
human beings. In order to acquire this knowledge I have received so 
much aid from Mr. G. E. Gordon that I wish to acknowledge my indebted- 
ness to him for placing at my disposal the fruits of his many years of study 
and practical observation on the feeding, breeding, and lactation of cows. 

The first nutritive period, which for purposes of simplicity I have arbi- 
trarily made to represent the first twelve months of life, is obviously, from 
what I have already told you, the most important one of the three. In this 
period the infant may be fed by a number of methods. It may be nursed 
by its mother, or a wet-nurse, or an animal, or it may be nourished by food 
especially prepared from the milk of one of these. 

I. MATERNAL FEEDING-. — The first of these methods, the maternal, 
is so far superior to any other which has ever been known that I shall 
assume that it is the best, and the one from which in almost every particular 
all others should be copied. 



FEEDING. 159 

The relative advantage of the milk-supply received from a primipara or 
a multipara is not of so much importance in the case of mothers as in that of 
wet-nurses. I shall therefore defer what I have to say on this subject until 
I speak of the latter, merely reminding you of what I have told you con- 
cerning them in a previous lecture (Lecture IV., page 100). 

Normal Maternal Conditions. — The assumption that the maternal 
is when normal the ideal source of infant food-supply presupposes many 
important conditions concerning the mother and the function of her mam- 
mary glands. She should be strong and healthy, of an even, happy tem- 
perament, desirous of nursing her infant, and have time to devote herself to 
this special duty during the whole period of her lactation. She should have 
a sufficient supply of milk, and should be willing to regulate her diet, her 
exercise, and her sleep according to the rules which will best fit her for her 
task. These may be said to be the ideal conditions which we endeavor to 
obtain for an infant which is to be nursed under the most favorable circum- 
stances. It is true that Avomen who are far from vigorous nurse their 
infants with seemingly good results, and that a frail, delicate-looking mother 
may have an abundant supply of good milk. These are exceptions, how- 
ever, which make the principles just stated all the more true. We must 
have some general principles to guide us in our endeavor to perfect the 
nutriment of infants as a class, or we shall surely in many instances do 
serious harm to the individual. 

Contra-Indications to Maternal Feeding. — With few exceptions, 
the mothers who have uncontrollable temperaments, who are unhappy, who 
are unwilling to nurse their infants, who are hurried in the details of their 
life, who are irregular in their periods of rest and in their diet and exercise, 
are unfit to act as the source of food-supply for their infants. Even if their 
milk happens to be sufficient in quantity, it will probably be so changeable 
in quality as to be a source of discomfort and even of danger rather than 
the best nutriment for their offspring. It is far better for such mothers not 
to attempt to nurse, but to adopt some other method of feeding. It is of 
still greater importance that mothers who are suffering from some chronic 
disease, or one which their infants may directly inherit, should give up 
all thoughts of nursing. Where there is no question of disease in the 
mother, it is our duty to investigate, and, if possible, to counteract the 
other contra-indications to nursing, often only caused through ignorance 
of what to us seem very simple truths, but which to the young mother are 
enveloped in mystery. There is, then, a double necessity for studying in 
the closest detail the conditions which constitute a normal lactation. First, 
that, knowing what is normal, we should at once recognize what is ab- 
normal, and, by the intelligent use of our knowledge, render possible an 
apparently unsuccessful attempt to nurse. Second, that Ave may know 
exactly on what the normal and vital conditions of a successful nursing 
depend, in order that we may understand what we should copy in substitute 
feeding. 



160 



PEDIATRICS. 



It is these normal and vital conditions which I shall endeavor to explain 
to you, and which, for the reasons just stated, you must not look upon as 
trivial, for I have found them of the greatest value both in the manage- 
ment of human-breast milk and in the regulation of infant feeding. The 
maternal, then, being the ideal method, I shall begin by showing you an 
actual illustration of this method. 

Nursing Mother. — Here is a young mother (Case 60), perfectly 
healthy and strong, in the act of nursing an infant. 



Cases 60 and 61. 




Infant 5 months old. 



Weight, 9800 grammes (about 213^ pounds). 
4500 grammes (about 10 pounds). 



Birth-weight, 



The infant (Case 61) was healthy at birth, and has grown continuously, with regular 
weekly gains of about 250 grammes (about J pound). Its birth-weight was 4500 grammes 
(about 10 pounds), and it now weighs 9800 grammes (about 21| pounds). It is a fine speci- 
men of normal development produced by human milk, and is so large that it has had to be 
dressed in short clothes some months earlier than is usual. You will observe that this nor- 
mal nutrition depends in great measure on its birth-weight rather than on any phenomenal 
gain which it has made from month to month. You will understand this by referring to 
what I have said regarding weight in my lecture on Development (Lecture lY., page 103), 
where I have stated that the birth-weight is normally doubled in the first five months of 
life. I would also call your attention to what I shall speak of more in detail later, that it 
is not necessarily a milk of unusually good percentage which has produced this progressive 
increase in weight. It is merely a good milk adapted to the especial need of this particular 
infant, and it might not at all suit a number of other equally healthy infants. This fact, 
as you will soon understand, merely declares that practically there is no one combination 
of the elements in human milk which is the best for all infants, but that nature pro- 



FEEDING. 161 

vides a number of combinations all equally good provided that they are suited to the 
individual. 

You see that the natural method of feeding is by sucking. The infant should be placed 
in a comfortable position in its mother's arms, with its head and back supported. It should 
be made at once to understand that it is to begin its meal as soon as the breast is oflFered to 
it, and continue, with, of course, breathing-spells, until the meal is finished. The mother 
should herself preferably be sitting, as she can thus best manage and control the infant if it 
is inclined to be restless. 

Now notice more closely the method by which this infant is obtaining its food. The 
formation of its lips and buccal cavity are adapted to the mechanism of suction, and you 
see with what ease and perfect tranquillity it is receiving its food. The breast is so organ- 
ized that it provides a fresh supply of food at the required intervals. It prevents fermenta- 
tion of the food before it enters the infant's mouth, while at the same time the suction 
incites to action both the necessary digestive fluids of the infant and the function of the 
gland itself. The gland avoids a vacuum by collapsing as it is gradually emptied, and 
allows the food to flow continuously, thus obviating the tendency to exhaustion of the infant 
and prolongation of the nursing-time which necessarily accompanies a retarded flow of the 
milk. Finally, the breast is practically self-regulated as to the amount which it is required 
to provide according to the infant's age. A healthy infant should empty the breast with 
easy and uninterrupted sucking in about fifteen to twenty minutes. 

IN'iPPLES. — In certain cases the mother's nipple is so small or depressed 
that it is a source of much annoyance to the infant, and at times this inter- 
feres so serionsly with its obtaining the proper food-supply that its nutri- 
tion suffers, and some other method than nursing has to be substituted. It 
is here that the ingenuity of the physician is taxed to its utmost. Eyery 
kind of device may fail, and it is necessary patiently to try one after the 
other before deciding to giye up the nursing. Xipple-shields should be 
experimented with, and will sometimes obyiate the difficulty. We should, 
howeyer, always impress upon the mother the fact that the yalue of her 
milk as a food may be entirely destroyed if foreign elements are allowed 
to enter with it into her infant's mouth. This simply means extreme clean- 
hness of the glass shield and rubber nipple. In a few cases where I could 
absolutely trust the mother on account of her being able to appreciate 
intelligently the details of my instructions and the danger of not carrying 
them out, I haye allowed, for a short time, the use of rubber tubing con- 
nected with the nipple-shield in place of the direct attachment of the rubber 
nipple. When this is done, howeyer, fresh tubing should be used eyery day, 
as it is extremely difficult to cleanse the interior of a rubber tube as one can 
the rubber nipple, which can be turned inside out and scrubbed. I would, 
howeyer, decidedly state that I consider, except in these rare instances, the 
use of rubber tubing to be an abomination which should neyer be toler- 
ated under other circumstances, and especially in feeding from the bottle, 
where its use is absolutely unnecessary. 

Where the nipples are yery tender and cause great discomfort to the 
mother during the nursing, their condition frequently becomes so serious an 
obstacle as to prevent nursing altogether. This change, howeyer, should 
not be thought of for at least several days, or until it is absolutely certain 
that the exquisite pain is more than the mother is willing or able to endure. 

11 



162 PEDIATRICS. 

It is often the case that after a little time of the greatest suffering from 
tender or excoriated nipples the whole difficulty will pass away and the 
mother be able to nurse her infant with comfort. I know of no especial 
treatment which will prevent this condition of the nipples from arising, nor 
of any way by which it can be quickly cured. Bathing with cold water 
before and after the nursing, and thus keeping the tissues in a healthy con- 
dition, appears to be as successful as the application of any medicaments. 

Mastitis. — Another trouble which may arise during the nursing period 
is a disturbance of the mammary gland itself, sometimes amounting merely 
to a stasis in its milk production, but again going on to inflammation. The 
latter is a serious matter, and should at once be placed in the hands of a 
skilful surgeon. The former condition requires great care in its manage- 
ment. Gentle massage from the periphery of the gland towards the nipple, 
amounting in fact to merely a delicate stroking with the ends of the fingers, 
is an important part of the treatment. The breast should be withheld from 
the infant for about twenty-four hours, and the milk from time to time 
drawn in small quantities by means of a properly-adjusted breast-pump. 
The breast should also be carefully supported by a swathe. If these meas- 
ures are begun as soon as there are any indications of disturbance in the 
breast, these abnormal conditions soon disappear. The indications referred 
to consist in the appearance of hard swellings in place of the usual soft 
elastic condition of the milk glands. These swellings may occur without 
any especial pain, but on palpation they are usually tender to a greater or 
less degree. 

Breast-Pump. — In regard to the use of the breast-pump there is a great 
difference of opinion, but I have very decided views on this subject, and 
believe that those who have opposed its use have been influenced to a great 
degree by what they have seen in their hospital practice, and also by the 
views of others who have, in like manner, met with unfortunate results in 
lying-in hospitals. It is well known that all inflammatory conditions about 
the breast are more likely to occur in hospitals than under conditions where 
the woman is less likely to be exposed to pathogenic organisms. This should 
be taken into account when we are deciding whether or not to use a breast- 
pump. In my experience, acquired in a great degree from my private 
practice, where every precaution in regard to cleanliness, fresh air, and 
good ventilation could be obtained, I have never met with any bad results 
from the use of the pump. 

In regard to the relation of micrococci to inflammation of the breast, 
according to Zweifel and Doderlein there are in mastitis two varieties of 
organisms, the staphylococcus pyogenes aureus and the streptococcus pyo- 
genes, but never the staphylococcus pyogenes albus. They admit that other 
varieties may perhaps be found on closer investigation, but at the same time 
they consider it striking that in all their cases there were never any local or 
general symptoms caused by the staphylococcus pyogenes albus, although 
that they were virulent was proved by their inoculation of mice. There 



FEEDING. 



163 



Pig. 40. 



is not much doubt that these pathogenic organisms gain access to the gland 
through the nipple. 

I have already said that the infant may not be able to hold the nipple 
with suificient firmness on account of some abnormal condition of the nipple 
itself 

Under certain circumstances, even where the nipple is well formed, the 
infant has insufiicient suction-power to obtain its food, though the food itself 
may be perfectly adapted to its digestion. In these cases we often find that 
it cannot or will not be induced to obtain its food through a shield and 
rubber nipple or from rubber tubing. The breast-pump may then become 
of great value, as in the case of an infant that was under my care during 
the hot weather of June, July, and August. 

This infant (Case 62) was seven months old, and was djing of starvation, as I had not 
been able to prepare for it a food which it could digest and thrive on. (This was before milk 
laboratories were established.) It was totally unable to nurse, although the breast-milk was 
a good one and agreed with it perfectly when it was introduced into its mouth with a spoon. 
The milk was pumped from the breasts at regular intervals and given to it from a bottle for 
over three months with the greatest success, the infant thriving, and at the end of that time 
being in a perfectly healthy condition. 

This case shows the exceptional but at times very great value of the 
breast-pump. 

As I shall later have occasion to speak 
of the use of the pump in various instances, 
not only for relieving the breast but for ob- 
taining milk for purposes of analysis, I will 
show you the form of piunp which I am in 
the habit of using. 

The apparatus should be one which can 
be carefully cleansed, and should, therefore, 
preferably be made of glass. No one special 
pump will, in all probability, suit every case, 
and it is of importance that you should use 
the greatest care in adapting the pump to the 
individual. As I have stated, however, this 
is the one which in most cases I have found 
to be suitable. When applied to the woman 
it should cause little or no pain or discom- 
fort. You see that the part which is adapted 
to the nipple is like an ordinary nipple- 
shield. This is attached to a glass bulb, into 
which the milk falls as it is drawn from the 
breast. The mechanism is very simple. A 
vacuum can be produced in the glass bulb 

by means of suction through a rubber tube attached to a rubber bulb with 
its valve working backward. This is a for better method for producing 




Broast-iHinip. 



164 PEDIATRICS. 

suction than the direct application of the mouth to the end of the rubber 
tube, which under all circumstances should, if possible, be discountenanced. 

MILK. — The product of the mammary gland of all mammals is 
essentially the same. It is composed of elements which in an individual 
milk resemble the corresponding elements in all the others. Although the 
attempt has long been made, and may in the future prove to be successful, 
to distinguish between the component parts of each element, yet at present 
we must, with few exceptions, accept each element as a whole and as alike 
both in human beings and in animals. This must practically be done until 
the analytical and physiological chemists provide us with much more exact 
data on which we can depend in elaborating our methods of infant feeding. 
It is the combination of the various elements of the mammary gland which 
makes the resulting product characteristic of the special mammal, and it is 
therefore best first to describe this uniform product as a whole and then 
to study it as it occurs in its various combinations, whether in human beings 
or in animals. 

In addition to the general principles which I explained to you in my 
last lecture, a number of physiological facts regarding milk as a whole 
become of great interest and of the utmost importance when we attempt to 
modify or change the product of the mammary gland. 

Formation. — Bunge's investigations on the comparison of tissues show 
that the mammary gland abstracts from the blood very nearly the amount 
of salts found in the tissues. According to Foster, whose remarks on this 
subject I quote freely, milk is the result of the activity of certain of the 
protoplasmic cells occurring in the epithelium of the mammary gland. So 
far as we know, the fat is formed in the cell through a metabolic action of the 
protoplasm. Microscopically, the fat can be seen to be gathered in the epi- 
thelial cell in the same way as in a fat-cell of the adipose tissue, and to be dis- 
charged into the channels of the gland either by a breaking up of the cells 
or by a contractile extrusion very similar to that which takes place when an 
amoeba ejects its digested food. This observation is thoroughly supported 
by other facts. Thus, the quantity of fat present in the milk is directly 
increased by proteid food, but is not increased by fatty food ; on the con- 
trary, it is diminished. In fact, proteid foods increase and fatty foods 
diminish the metabolism of the body. A bitch fed on meat for a given period 
gave off more fat in her milk than she could possibly have taken in her food, 
and that, too, while she was gaining in weight, so that she could not have 
supplied the mammary gland with fat at the expense of fat previously exist- 
ing in her body. We also have evidence that the caseinogen is, like the fat, 
formed in the gland itself. When milk is kept at 35° C. (95° F.) outside of 
the body the caseinogen is increased at the expense of the albumin. When 
the action of the cell is imperfect, as at the beginning and end of lactation, 
the albumin is in excess of the caseinogen ; but so long as the cell possesses 
its proper activity, the formation of caseinogen becomes prominent. That 
the milk-sugar also is formed in and by the protoplasm of the cell is indi- 



FEEDING. 165 

cated by the fact that the sugar is not dependent on a carbohydrate food, 
and is maintained in abundance in the milk of carnivora when these are 
fed exckisively on meat as free as possible from any kind of sugar or 
glycogen. We thus have evidence in the mammary gland of the forma- 
tion, by the direct metabolic activity of the secreting cell, of the represen- 
tatives of the three great classes of food-stuifs, proteids, fats, and carbo- 
hydrates, out of the comprehensive substance protoplasm. 

Nervous Disturbances affecting the Milk. — The secretion and 
ejection of milk are very evidently under the control of the nervous system, 
which produces marked changes in both the quantity and the quality of the 
mammary product in proportion to the relative nervous excitability of the 
special mammal. Women are especially sensitive in this respect, and when 
living in the midst of our modern civilization, so harmful for the pro- 
duction of good nursing, present an exaggerated example of disturbance 
of the equipoise of the mammary gland. The chemistry of the equipoise 
and lack of equipoise of the mammary product appears to be closely con- 
nected with its proteid element. This element is known to be a compound 
one and decidedly complex, but for purposes of illustration we can safely 
say that the word albuminoid or proteid is a general term, which includes 
caseinogen and albumin ; also that these factors of the complete whole vary 
in their proportions to each other according as the mammary fimction is or 
is not in a state of equipoise. In the colostrum period, and probably in the 
analogous periods represented by the abnormal conditions already spoken 
of, the albumin is in excess in proportion to the caseinogen, while as the 
equipoise of the function becomes more complete the caseinogen is increased 
proportionately to the albumin. Probably at the end of lactation, as in 
the beginning, we shall find this same condition of richness of albumin and 
deficiency of caseinogen. This increase of the albumin at the expense of the 
caseinogen explains what I have previously told you concerning the excretory 
fimction of the gland at times becoming more prominent than the secretory. 

These nervous disturbances, however, may also cause, as I shall describe 
to you later, an over-production of the total proteids, as shown by their per- 
centages. In some cases also the fat has been found to be much reduced in 
its total percentage. Instances of this have arisen where, as observed by 
Zukowski and quoted by Jacobi, seasons of fasting with their accompanying 
excitement of the emotions have induced such a disturbance of the equi- 
librium of the milk that the fat has been found to be decreased to the low 
percentage of 0.88, with the result that the infant has become sick and 
given evidence of impaired nutrition. These same nervous influences in 
all probability have to a greater or less degree their analogy in the milk- 
product of all mammals. 

Constituents and Properties. — Milk consists of a large amount of 
water and a comparatively small amount of solids. The solid constituents 
comprise, in varying proportions, certain proteid elements, faf, sugar, and 
mineral matter. 



166 PEDIATRICS. 

^^Milk is an emulsion, the fats existing in the form of globules of 
varying but usually minute size. It is this condition of the fat which 
gives milk its peculiar white color.^^ (Foster.) 

The specific gravity, reactio7v, and other properties can best be spoken of 
when describing the milk of an especial mammal. 

The closely analogous conditions, however, of the earliest days of lacta- 
tion in the woman and in the cow lead me to describe in my general remarks 
on milk the colostrum period of these two mammals. 

Colostrum. — During the early days of lactation the mammary gland 
secretes a somewhat different fluid from that which is produced by it later. 
The milk at this period is called colostrum, and the period is called the 
colostrum period, on account of certain elements called colostrum corpuscles 
which are present in the milk. I have already spoken of the connection 
between loss in weight of the infant (Lecture IV., page 100) and the 
presence of colostrum in the milk ; also of the excess of albumin over the 
caseinogen in colostrum milk. 

Colostrum is supposed to have a somewhat laxative effect, and in this 
way to aid in displacing the meconium. Whether it is of any especial 
advantage to the infant is a question of much doubt, for it appears to me, 
and it will, I think, be understood by you, from what I have already told 
you regarding the mammary gland, that the appearance of these colostrum 
corpuscles is simply an indication that the equilibrium of the mammary 
gland has not been established, or has been disturbed, and that it is an evi- 
dence of disease rather than of health. It may be that the not infrequent 
disturbance of the infant's digestion, amounting at times to acute conditions 
of fermentation, is produced by an exaggerated abnormal condition occur- 
ring in the colostrum period as well as by the return of the colostrum at 
irregular periods. This may be the reason why numbers of infants are made 
sick by their mothers' milk at an early period of lactation. 

The analysis of colostrum milk is something which as yet has not been 
thoroughly studied. Whether it will be of much importance or not is a 
question to be determined in the future. It may, however, prove to be 
of considerable use to us when we attempt to prepare a substitute food for 
the early days of life. It is possible that a combination of elements corre- 
sponding in their percentages to those which are shown by the analysis 
of the colostrum, but free from the colostrum corpuscles, may be found 
to suit best the infant's digestive function at this early period of its life. 
I have under one of these microscopes a drop of colostrum milk (Fig. 
41) taken from a cow, and under the other a drop (Fig. 42) taken from 
a woman. 

In addition to the fat-globules of various sizes which you see floating in 
this film of milk you will notice the large cells which occasionally appear in 
the field. These are the colostrum corpuscles. The one to the right above 
the centre in the cow's milk appears to be about one-third larger than the 
one to the left and below the centre in the woman's milk. 



Fig. 41. 




Golostrum milk from cow, (Photo-micrograph.) 



Fig. 42. 




Colostrum milk from woman. (Photo-micrograph.) 



FEEDING. 167 

An analysis (Analysis 6) made by Dr. Harrington of this cow's milk 
colostrum gave the following results : 

ANALYSIS 6. 

Fat 1.71 

Milk-sugar 4.90 

Proteids 1.72 

Ash 0.79 

Total solids 9.12 

Water 90.88 

100.00 

This table (Table 33) represents the analyses of some specimens of 
human colostrum milk, which I have also had made by Dr. Harrington : 

TABLE 33. (Harrington.) 

I. II. III. IV, V. 

Fat 1.40 0.68 2.40 5.73 4.40 

Milk-sugar and proteids . . . 9.44 11.53 11.15 10.69 11.27 

Ash 0.17 0.31 0.25 0.16 0.21 

Total solids 11.01 12.52 13.80 16.58 15.88 

Water 88.99 87.48 86.20 83.42 84.12 

100.00 100.00 100.00 100.00 100.00 

These analyses, while not determining minutely the percentages of the 
elements of colostrum milk, tend to show the great variations which occur 
in this period and how little knowledge we have concerning it. 

In speaking to you about the colostrum in my lecture on normal devel- 
opment (Lecture IV., page 100) I stated that the colostrum corpuscles should 
disappear from the milk iu a week or ten days after birth. They diminish 
rapidly in numbers during the second week, and if they continue into the 
third week, or return at any time during the lactation, they almost inva- 
riably cause disturbance of the infant's digestion ; they also become an 
indication that lactation should be suspended temporarily, and, if they 
continue, that it should be entirely given up. 

On the disappearance of the colostrum corpuscles the milk should rap- 
idly acquire its normal equilibrium, and, with the exception of its well-recog- 
nized daily variation, should show a comparative uniformity in its analysis 
during the whole of the nursing period, and until the equilibrium of the 
mammary gland is again disturbed, as at the end of lactation. 

HUMAN MILK. — I have stated the general conditions which affect 
the mammary product of all animals. I will now describe especially what 
is known concerning human milk. 

Quantity. — I have already told you how the mammary gland adapts 
its quantity to the amount needed. The question so often arises as to 
whether the total amount to be secreted for each feeding can in any way be 
increased, that it is well to mention this now and to dispose of it. Beyond 
the general conditions affecting the mammary product of the mother, which 
I have spoken of, I know of no means of increasing the flow of milk. I 



168 ' PEDIATKICS. 

have little confidence in galactagogues in the form of drugs or special foods, 
for their numbers betray their inefficiency. The milk becomes lessened in 
amount from many causes. Some of these are identical with those which 
commonly produce any disturbance of its equilibrium such as I have men- 
tioned. Certain drugs, such as belladonna, will in some individuals cause 
a notable decrease in the flow of the milk, and must, therefore, be given 
with care during the nursing period. An active cathartic will also lessen 
the milk, as will also a diet composed of solid food and very little water. 

Quality. — The quality of the mother's milk is of the utmost impor- 
tance to the welfare of the infant. It is very necessary, therefore, that we 
should thoroughly investigate and clearly understand what the normal com- 
position and characteristics of her milk should be. This can be done only 
by having analyses made by expert chemists. Even with the aid of these 
analyses the information which is obtained concerning the percentages of 
the various elements is liable to be inexact in some of them. 

This is unfortunately true regarding the two elements fat and proteids, 
which are under any circumstances the ones most likely to vary, and we 
must especially allow for some slight error in the proteid percentage. 

The greatest practical assistance, however, can be obtained from these 
analyses, as they represent the true foundation for most of our work on 
infant feeding. I shall not attempt to describe the method of analysis which 
is used, as it is too purely a chemical question to be of practical use in clin- 
ical work. 

My analyses have in almost every case been made by Dr. Charles Har- 
rington. To obtain a specimen for analysis your hands should be sterile, 
and the breast and nipple should be carefully washed with sterilized water, 
and from 20 to 30 c.c. (5 to 8 drachms) of milk drawn by the breast-pump, 
Avhich, being made of glass, can also be thoroughly washed. The milk 
should then be poured into a sterilized bottle and tightly corked. It should 
immediately be taken to the chemist, and kept on ice until the examination 
is made. 

In every case it is very important to know the exact percentage of the 
fat, both from its being the most variable element and from its use in the 
determination of the percentages of the other elements. Any means, there- 
fore, which will procure the exact percentage of the fat should be made use 
of where for any reason a complete analysis cannot be procured. The most 
exact means for this purpose outside of the chemical laboratory is an appa- 
ratus called the Babcock Fat Tester, which I shall show and explain to you 
at the Milk Laboratory in a later lecture (Lecture IX., page 250). As this 
is not an expensive machine, it has seemed to me that in communities at 
a distance from an expert chemist, or where the people are unwilling to 
pay for a complete analysis, a Babcock machine could be owned jointly by 
a number of physicians and kept at some central place. 

The smallest amount of milk required for determining the percentage 
of fat with the Babcock machine is 17.50 c.c. 



FEEDING. 169 

NORMAL LACTATION. — In order to understand the many varia- 
tions which are continually arising in human milk during the period of 
what may be considered a normal lactation, Ave should clearly appreciate 
the various conditions existing in human milk and its composition as de- 
termined by a study of a very large number of individual specimens of 
milk. In this way we obtain a knowledge of the composition of the 
average human milk. 

Microscopic Examixatiox. — The mere microscopic examination of 
milk beyond the determination of the presence or absence of colostrum 
corpuscles and foreign matters, such as pus, blood, and epithelial cells, is 
too uncertain and misleading to be in any way depended upon, the chemical 
analysis being the only practical method which can be recommended. The 
truth of this statement was lately impressed upon me when a physician 
skilled in the use of the microscope sent me a specimen of woman's milk 
which he stated was rich in fat, but which the analysis showed to have only 
a little over one and a half per cent, of this element. 

The presence of an undue amount of yellow coloring matter is at times 
very misleading. I have also seen human milk which had a greenish color, 
evidently produced by some of the micro-organisms which are known to 
occur in cow's milk, but the nature of which is not yet fully determined 
and which under the microscope are not represented by anything abnormal. 

Clixical Examixatiox of Humax Milk. — The rules by which the 
percentages of the other elements of the milk can be deduced when once the 
percentage of the fat has been obtained by the Babcock machine are the 
same as those which I shall presently speak of in connection with another 
method of clinical examination, where, however, the determination of the 
fat is not so accurate as that by means of the Babcock. We cannot be 
too particular in regard to the accuracy of the method which we employ for 
obtaining an analysis of the milk ; yet, as the most accurate analysis can be 
obtained only through an expert chemist, a simple approximate clinical test is 
often very desirable, even though it is less accurate. Under these circum- 
stances the method employed by Dr. L. E. Holt, of Xew York, will be 
found to be of practical use. Holt does not assert that he reaches by his 
method anything but a fairly accurate knowledge of the percentages of the 
different elements of the milk, and he recommends it for the analysis of 
human milk only where a better one cannot be had. • His results are based 
upon the comparative examination by his method of a large number of 
specimens of milk and on the following well-known chemical facts : 

(1) That the specific gravity of human milk varies between 1029 and 
1032, the average being 1031, at 21.11° C. (70° F.). Abnormal variations 
occur between the limits of 1017 and 103(3. An increase in the fat lowers 
the specific gravity ; an increase in the other solids raises it. 

(2) That the salts do not vary much in their amount in ordinary human 
milk. They are too insignificant in ]iercentage to afiect the specific gravity, 
and in the clinical examination of milk they need not be considered. 



170 PEDIATRICS. 

(3) That the proportion of the sugar is nearly constant in human milk 
under all circumstances. This point has been emphasized by all the chemists 
who have made milk analyses. 

(4) That in striking contrast to this uniformity in the sugar are the wide 
variations met with in the fat and jproteids, as is shown by the following 
tables : 

TABLE 34. 
Variations in Fat. 

From 43 analyses by Leeds 2.11 to 6.89 per cent. 

" " " Konig 1.71 to 7.60 " " 

" 29 " " Chem. Lab. Coll. Phys. and Sur. N. Y. . 1.12 to 6.02 " " 

TABLE 35. 

Variations in Proteids. 

From 43 analyses by Leeds 0.85 to 4.86 per cent. 

" " " Kdnig 0.57 to 4.25 " " 

" 29 " " Chem. Lab. Coll. Phys. and Sur. N. Y. . 1.10 to 3.62 " " 

(5) That to determine the composition of milk we must have a knowl- 
edge of the proportions in which the two elements which vary most widely, 
namely, the proteids and the fat, are present. 

(6) That from the fact that the proportion of sugar is so nearly constant 
and that the salts are in such small amounts, we may for clinical purposes 
consider the specific gravity as modified solely by the fat and the proteids. 

(7) That there is no known method of determining directly the per- 
centage of the proteids in the milk by a clinical examination, and that a 
complete chemical analysis by an expert is the only one that can be accepted 
as accurate. It is possible, however, from a knowledge of the specific 
gravity and the percentage of the fat, to make an approximate calculation 
in regard to the percentage of the proteids, at any rate sufficiently close to 
determine whether in a given case they are near the normal, or are in very 
large or very small proportions. 

Method of Examination. — It is necessary first to determine the 
specific gravity of the milk and the percentage of the fat. 

To determine the composition of the milk by Holt's method the only 
instruments needed are a small hydrometer, a pipette, and a glass-stoppered 
cylinder graduated in one hundred parts and holding about 10 c.c. 

The specimen of milk for analysis should be taken from the " middle 
milk,^' and it is important that the milk should be freshly pumped and 
handled as little as possible, also that the graduated glass cylinder should 
be scrupulously clean, otherwise the milk will often sour before the cream 
has had time to rise. This is particularly true in summer. 15 c.c. (J 
ounce) is the amount of milk required for the test. 

Specific Gravity. — The specific gravity is obtained by means of the 
hydrometer, for the use of which only 15 c.c. (J ounce) of milk are 
needed. 

Percentage of the Fat. — The percentage of the fat is determined 



FEEDING. 171 

by estimating the percentage of the cream, which is ascertained by the 
following method : 

The glass-stoppered cylinder is filled with milk exactly to the upper line, 
which is marked 0. The pipette should be used for putting the last few 
drops into the cylinder, care being taken not to allow the milk to run down 
the inner side of the tube, since this somewhat obscures an exact reading. 
The cylinder is then corked and allowed to stand for twenty-four hours at a 
temperature of as nearly 21.11° C. (70° F.) as is practicable. A variation 
of a few degrees on either side of this point is unimportant. If, however, 
the variations are wide, the rapidity with which the cream rises is some- 
what modified. 

In the great majority of cases the lower line of the cream has be- 
come sharply defined at the end of twenty-four hours, and can then be 
recorded. If this is not the case, the milk should be allowed to stand for 
six hours longer before reading the percentage. 

By comparing the percentage of the cream with that of the fat, as de- 
termined by a chemical analysis of the same specimen, it has been discovered 
that the ratio of the cream to the fat is very nearly 5 to 3, and for clinical 
purposes it can be so estimated. 

Estimation of the Proteids. — In estimating the proteids certain sup- 
positions must and can be fairly accepted : 

(1) Supposing the proteids to remain unaltered : if the percentage of fat 
be low, the specific gravity will be high, but if high, the specific gravity will 
be low. 

(2) Supposing the fat to remain unaltered : if the percentage of the pro- 
teids be high, the specific gravity will be high, but if the percentage of the 
proteids be low, the specific gravity will be low. 

If, therefore, the fat and the specific gravity be known, the proteids may 
be estimated by the following rules : 

(1) If the percentage of the fat be found to be high, that is, from eight 
to ten per cent., and the specific gravity high, that is, from 1033 to 1034, 
we may assume that the proteids are also of high percentage, otherwise the 
excessive fat would bring the specific gravity below the normal average. 

(2) If the fat be found to be of low percentage, that is, from three to 
four per cent., and the specific gravity high, we may assume the proteids to 
be nearly normal, since the high specific gravity is explained by the small 
proportion of fat. 

(3) If the percentage of fat be high and the specific gravity low, the 
proteids may be assumed to be normal, since the variation in the specific 
gravity is explained by the low percentage of fat. 

(4) If the percentage of fat be low and the specific gravity low, the 
percentage of the proteids is also low, since otherwise the small proportion 
of fat would make the specific gravity above the average. 

Of course it is only the wide variations in the proteids which can be 
recognized by these rules ; but these variations are often very important. 



172 PEDIATRICS. 

We can then say that, knowing the specific gravity and calculating the 
fat as three-fifths of the known percentage of the cream, we can judge 
whether the proteids are nearly normal, very high, or in very small amount. 
Holt asserts that the estimation of the composition of milk by this method 
is as exact as that obtained by ordinary examinations of urine. 

Chemical Analyses. — There is no doubt of the great value of an 
expert chemical examination of the milk in cases where an infant is not 
thriving, although apparently receiving a sufficient quantity of milk from 
its mother. On the other hand, you must remember that a chemical analysis 
will never give any information regarding the quantity of the milk, and it 
often happens that where such an analysis has proved the quality to be 
good, the infant is not thriving because the quantity of the milk is very 
small. The symptoms which indicate that it is the quantity of milk which 
is at fault rather than the quality are that the breasts at the nursing time 
are soft, and that only a small quantity of milk can be extracted from them 
by the breast-pump. A period of nursing longer than the usual fifteen to 
twenty minutes before the child is satisfied should make us suspicious that 
the milk is lacking in quantity. We can also determine the actual quantity 
of the milk which the child has imbibed at an especial nursing by means 
of weighing, as described in a previous lecture (Lecture IV., page 79). 
A number of observations at different nursings in the day must, however, 
be made before a correct conclusion can be reached by this latter procedure. 

Average Analysis of Human Milk. — I will now call your atten- 
tion to this analysis (Analysis 7) of average human milk, which represents 
the work of such chemists as Konig, Forster, Meigs, Harrington, and others, 
and the mammary product of a large number of women of all nationalities. 
The figures opposite each element are the percentages which that element repre- 
sents as a part of the total solids, without reference to its own composition. 

ANALYSIS 7. 
Aveimge Human Milk. 

Keaction Slightly alkaline. 

Specific gravity 1028-1034 

Water 87-88 

Total solids 13-12 

Fat 3-4 

Sugar 6-7 

Proteids 1-2 

Total ash 0.1-0.2 

You can obtain from this analysis a fair knowledge of the normal 
composition of human milk, and you will at once notice its simplicity and 
its few constituents. 

Reaction. — The normal reaction of human milk when freshly drawn 
with suitable precautions is, as a rule, alkaline ; it is, however, sometimes 
neutral, rarely acid, and in the latter case it may be considered abnormal. 

Specific Gravity. — The specific gravity varies normally to a considerable 



FEEDING. 173 

degree on account of the variations in temperature to which the milk hap- 
pens to be exposed at the time when the specific gravity is taken. When, 
however, the milk has its average normal composition, and the temperature 
to which it is exposed is 15.50° C. (60° F.), its average specific gravity is 
1031. 

Water. — One of the most important chemical facts to be remembered 
for clinical purposes is the very large proportion of water which is found in 
normal human milk, for it teaches us that it is a highly diluted food by 
which the best results can be obtained in infant feeding. It also explains 
to us how careful we should be not to overtax the comparatively slight 
power for absorbing a concentrated food which exists in the early months 
of life. 

Pat. — The fat of human milk is made up of palmitin, stearin, and olein. 
About two per cent, of the total fat consists of the glycerides of butyric, 
caproic, caprylic, and myristic acids. The production of animal heat is 
so very important a part of the infant's well-being that it is not surprising 
w^e should find so large a percentage of fat as well as of sugar in the food 
which is provided for it. The presence of fat in the milk is not only for 
the purpose of nutrition, but also as a means for the maintenance of bodily 
heat. This latter function of the fat cannot with impunity be trifled with, 
and is essential for that active metabolism of which I have spoken in an 
earlier lecture (Lecture IV., page 100). A proper amount of fat is probably 
of great aid in the regulation of the fsecal discharges. An amount of fat 
proportionate to the proteids is presumably necessary, or at least of great 
aid, in their proper digestion. We should naturally expect that unless the 
standard percentage of fat, or at least a near approach to it, existed in the 
mother's milk, trouble would be likely to arise wdth her infant, and this cor- 
responds with my experience in cases where the special ingredient which has 
interfered with the success of the nursing has been the fat. I have found 
clinically that where the fat was much lessened the nutrition suffered, that 
the digestion was not good, and that there was a tendency to constipation, 
while where its percentage was decidedly above the standard the digestion 
was weakened, there was a tendency to diarrhoea, and in consequence a 
resulting poor nutrition. 

These clinical observations at once suggest to us that in the management 
of infant feeding we must recognize the existence of two important con- 
ditions. One of these is the digestion of the infant, the other is its nutri- 
tion. These two requirements for a successful lactation are based on the 
facts that the milk may be easily digested but not nutritious, and that it may 
be highly nutritious but difficult to digest, so that it is the equilibrium of 
these two conditions which produces a perfect infantile development. It is 
especially important that the percentage of fat in an infant's food should be 
within the limits of the normal variations Avhich are found in the milk of 
healthy nursing women with healthy infants. For, although it is admitted 
that a large percentage of surplus fat is frequently found in the fkces of 



174 PEDIATRICS. 

infants whose digestion and nutrition are normal, and whose food is human 
milk, yet we have no more right to conclude from this that a small percent- 
age of fat is sufficient for nutrition, or that a large surplus will be eliminated 
by the faeces, than we have to assume that there is too much oxygen in the 
blood because we find a certain surplus of oxygen in the arterial blood 
which is returned to the lungs in the pulmonary veins. In fact, it is far 
more probable that nature introduces a certain percentage of fat into human 
milk with a purpose which can be accomplished only by that percentage, so 
that it is an error to change this percentage beyond the variation which com- 
monly occurs in average human milk. 

Sugar. — The form of sugar which is found in human milk is called 
milk-sugar, and, as you see by referring to this average analysis (Analysis 
7), has the highest percentage of all the elements constituting the total solids 
of the milk. The sugar is more digestible than the fat, but does not have 
so much potential energy — that is, so much heat-producing power in a 
given weight — as does the fat, which is to the sugar as 2.4 to 1. The 
conversion of milk-sugar into lactic acid gives rise to many of the changes 
occurring in milk. 

Proteids. — Although there have been a great many different opinions 
expressed as to the average percentage of the total proteids in human milk, 
we are led at present to believe that it is normally one or two per cent. 
The proteids or albuminoids, for the terms are synonymous, are general 
names including caseinogen and an albumin (lactalbumin), which in its 
general features resembles ordinary serum-albumin, but the chemistry of 
these elements is too obscure to make it worth while to consider them 
practically and clinically more minutely. We recognize that this albumin 
is present in small and variable quantities when the mammary gland and 
its secretion are in a normal condition, while at the time when the glandular 
function is being established, and during periods of glandular disturbance, 
it becomes proportionately larger in amount. I have already explained to 
you sufficiently the relative proportion under varying circumstances which 
the caseinogen and albumin bear to each other, and I will merely add to 
what I have already said, that the proteids, as a whole, are a valuable 
source of information to us when we are determining whether the milk is 
normal or abnormal. 

Ash. — The ash, which is sometimes called the mineral matter and some- 
times the salts, has an average percentage of from 0.1 to 0.2. Up to the 
present time, although a certain number of analyses of the ash of human 
milk have been made, yet the results, for various reasons, have been deemed 
unsatisfactory. So large a quantity of milk is needed for a reliable 
determination of the percentage of each element which makes up the total 
amount, that this in itself has been an important reason for failure in 
accuracy. The determination of the mineral matter of cow's milk has not 
been attended with the same difficulty, and its percentages have been esti- 
mated with comparatively reliable results. It has always been supposed that 



FEEDING. 175 

there is a radical difference between the percentages of the mineral matter 
of cow^s milk and that of human milk. The exact knowledge of the per- 
centages which exist in the latter has become of still greater importance 
since such decided advances have been made in the modification of the 
elements of the former. With a view of making some advance in this 
difficult question, and of providing for the milk-modifiers of the future a 
more exact basis for perfecting a substitute food resembling as closely as 
possible the product of the human breast, I undertook, in the spring of 
1893, to procure an unusual and sufficient quantity of human milk for 
analytical purposes. In the course of a few weeks, by means of the concerted 
action of numerous assistants, I collected five and a half liters (about six 
quarts) of human milk, which is an unusually large quantity for experi- 
mental purposes. This milk was immediately reduced to its mineral con- 
stituents in the laboratory of Dr. Charles Harrington. The analysis of 
this large amount of mineral matter was then made by Dr. Harrington and 
Dr. L. P. Kinnicutt, with the following results : 

ANALYSIS 8. 
The Ash of Human Milk. 

Unconsumed carbon 0.71 

Chlorine 20.11 

Sulphur 2.19 

Phosphoric acid 10.73 

Silica 0.70 

Carbonic acid 7.97 

Iron oxide and alumina 0.40 

Lime 15.69 

Magnesia 1.92 

Potassium 24.77 

Sodium 9.19 

Oxygen (calculated) 6,16 

100.54 
Coynposition of the Ash calculated from the above Analysis. 

Uncombined carbon 0.71 

Calcium phosphate 25.35 

Calcium silicate 1.35 

Calcium sulphite 2.11 

Calcium oxide 1.72 

Magnesium oxide 1.91 

Potassium carbonate 24.93 

Potassium sulphite 8.04 

Potassium chloride 12.80 

Sodium chloride 23.13 

Iron oxide and alumina 0.40 

102.45 

A closer approximation to the relative proportions of the salts in the 
form in which they occur in milk, calculated from the above analysis, may 
be stated as follows : 



176 PEDIATRICS. 

Calcium phosphate 23.87 

Calcium silicate 1.27 

Calcium sulphate 2.25 

Calcium carbonate 2.85 

Magnesium carbonate 3.77 

Potassium carbonate 23.47 

Potassium sulphate 8.33 

Potassium chloride 12.05 

Sodium chloride 21.77 

Iron oxide and alumina 0.37 

100.00 

In comparing the previous analyses which have been made, and which 
can be found in Konig's Nahrungsmittel, II., 2® Auflage, with this new 
analysis, we must remember that the previous analyses were made some 
years ago. In the last few years the processes which have been employed 
have been so much more exact that these results must be considered far 
more trustworthy than those made at an earlier date. It is not remarkable, 
therefore, that distinct differences should be found between this new analysis 
and the analyses which have hitherto been made, and presumably this last 
analysis is the correct one. It has been made with the greatest care, and 
by means of the most improved technique, by two eminently competent 
and well-known chemists, who in their work have acted as controls on 
each other. In this way great precision has been attained. 

The residue obtained from the evaporation of about six quarts of woman's 
milk was extracted with naphtha to remove the fat, and then ignited at a 
very low temperature so as to prevent the volatilization of the chlorides. 
The ignition was accomplished by placing the residue from the naphtha ex- 
traction in a platinum dish which was supported on a platinum coil inside 
of a larger platinum dish, the latter being heated with a free flame. Even 
at this low temperature a partial change in the composition of the ash took 
place, the sulphates being reduced to sulphites, but not to sulphides, as the 
ash on being carefully tested showed that sulphides were not present. All 
the carbonates of calcium and all the carbonates of magnesium were reduced 
to oxides. The ash also contained seven-tenths of one per cent, of uncon- 
sumed carbon. 

In woman's milk of course there would be no free carbon. All the 
calcium that did not exist as phosphate would be in the form of sulphate 
and carbonate, not of sulphite and oxide as found in the ignited ash. The 
magnesium would exist as carbonate, not as oxide, and the potassium as sul- 
phate, carbonate, or chloride. No sulphite of potassium would be present. 

The chief differences between this new analysis and all previous ones are 
as follows : 

(1) The phosphoric acid is less than half as much as previously reported. 

(2) The magnesium is also less than half as much. 

(3) Silica and alumina are present. They have not been returned in any 
previous analysis. 



FEEDING. 177 

Assuming the truth of the statement that the constituents of the mineral 
elements of human milk are subject to great fluctuation according to age 
and other causes, it is right to assume that the mineral matter examined bv 
Kinnicutt and Harrington, being the product of a large number of women, 
is a fair average specimen. 

From what I have already said you will understand that although 
chemical analyses enable us to work more intelligently, yet the conclusions 
which we can draw from them are far from being precise, owing to the 
variations which may occur and to the insufficient number of reliable 
analyses which have so far been made. We should therefore be extremely 
guarded in drawing conclusions, for the present merely looking upon these 
analytical results as important. It is very desirable that when reliable 
analyses are made they should be published, and thus as our information 
increases we shall be enabled to arrive at results which will greatly aid us 
in regulating the period of lactation. 

Yariatioxs in Milk. — We are led to expect that we shall find that 
where the milk is poor and does not agree with the infant there is an 
excess of proteids and a diminution of fat beyond what we have so far 
been able to determine as the normal average percentages of these two ele- 
ments. Again, where a variation takes place in the milk it is more likely 
to be found in the fat and proteids, as already stated, than in the sugar 
or the ash. I should also advise you to have a number of analyses made, 
on different days and at different times, in order that the error of an especial 
or temporary variation may be corrected. The importance of the assistance 
which can be gained from these analyses is, in my opinion, very great, and 
many more analyses should be made than we are now in the habit of 
deeming necessary. The question of expense should not for a moment be 
considered by those who can afford to have analyses made, for not only 
will real benefit come to their own children through money spent in this 
way, but these analyses, when published and collated, will prove of great 
value for the proper regulation of the feeding of infants in all classes of 
society. An error for which ^ve must always allow may interfere with the 
true analysis of the milk which the infant has actually received in its 
stomach at the end of the nursing, and is one which must necessarily invali- 
date the information which we receive from our analysis. I have already 
referred to this subject in speaking of the changes which arise from slight 
causes and influence the special specimen which is being analyzed. Thus, 
we should recognize that the milk varies considerably in its percentage of 
fat and total solids in the different periods of a nursing, and that the com- 
position of the milk which the infant has in its stomach may differ very 
widely from the composition of a specimen taken directly before or after the 
nursing. Harrington's analyses of the three periods of a milking will 
illustrate the meaning of what has just been said, and although they were 
made from the milk of a cow, yet, knowing the closely analogous conditions 
existing in human and in animal milk, we shall find them equally valuable 

12 



178 PEDIATRICS. 

in explaining the corresponding changes met with in woman^s milk. They 
are represented in this table (Table 36) : 

TABLE 36. 

Fat. Total Solids. Water. Ash. 

"Fore-milk" 3.88 13.34 86.66 0.85 

" Middle milk" 6.74 15.40 84.60 0.31 

"Strippings" 8.12 17.13 82.87 0.82 

The analyses of J. Reiset and Peligot are also of considerable interest as 
showing not only the increase of solids at the end of a milking, but also 
that this increase is mostly of the fat, and to a lesser degree of the proteids, 
and, as I have already stated, that a short interval of nursing increases the 
solid constituents in proportion to the water, the reverse of this being true 
where the intervals are long. 

Heidenhain explains this physiological phenomenon by saying that his 
investigations point towards the fact that during the pauses between the 
milkings the cells of the glands are growing. During this time a propor- 
tionately small amount of solids and a proportionately large amount of 
water are secreted, while the irritation of milking causes increased activity 
of the milk-cells, with a corresponding increase in the solid secretion and a 
lessening of the water. Peligot's table, giving the analysis of an ass's milk 
in three different portions, shows the relations of the solids both to the 
water and to one another : 

TABLE 37. (Peligot.) 

Ass's Milk. 

1st Portion. 2d Portion. 3d Portion. 

Butter 0.96 1.02 1.52 

Milk-sugar 6.50 6.48 6.50 

Casein 1.76 1.95 2.95 

His second table shows the changes of proportion according to the 
intervals of milking : 

TABLE 38. (Peligot.) 

Ass's Milk. 

Milking Intervals. 
13^ hours. 6 hours. 24 hours. 

Butter 1.55 1.40 1.23 

Sugar 6.65 6.40 6.33 

Casein 3.46 1.55 1.01 

The next table is also interesting, and should be recorded : 

TABLE 39. (Keiset.) 

Cow's Milk. 

Last Time - Percentage of Solids at 

since Milking. Beginning. End, 

12 hours 9.33 16.04 

6 " 12.80 16.06 

2J " 12.84 13.08 



FEEDING. 179 

Harrington's analyses of woman's milk showing the '^ strippings" of 
a two-hours interval and the '' fore-milk" of a twelve-hours interval are 
also of considerable interest : 

TABLE 40. (Harrington.) 

" Strippings," " Fore-Milk," 

2-hours Interval. 12-hours Interval. 

Total solids 15.32 10.14 

Water 84.68 89.86 



100.00 100.00 

With these chemical and physiological facts before us, we are forced to 
acknowledge that we must be very circumspect in the conclusions which 
we deduce from such analyses of human milk as have been made up to 
the present time. I have referred sufficiently to the errors which may 
arise in determining the percentage of the various elements which con- 
stitute the total solids, and I will once more merely state that an error 
in these conclusions where a correct chemical analysis has been made is 
less likely to occur from the sugar and the ash than from the proteids and 
the fat. 

Reasoning from the strong analogy which must exist between human 
milk and cow's milk, and being aware of the great variations which occur 
in the latter, we may assume that human milk is liable to vary in its com- 
position considerably with different milkings on the same day, and also with 
the milkings of the same hours on different days, so that at present we are 
not in a position to state that our knowledge of human milk is sufficiently 
exact to justify an attempt to formulate a table to show the composition of 
woman's milk at different periods of her lactation, however valuable such 
information may in the future prove to be. We must also understand that 
human milk of normal quality, and proving to be equally nutritious to the 
special infants that are fed on it, may vary considerably in the percentages 
of all its elements, and in the combinations of these percentages. This fact 
is well illustrated in this table (Table 41), showing the analyses of fourteen 
specimens of human milk all differing in the combinations of their different 
elements : 

TABLE 41. (Harrington.) 

Human Breast-Milk Analyses. 

[Mothers healthy^ and infants all digesting ivell and gaining in iveight.) 





I. 


II. 


III. 


w. 


V. 


VI. 


VII. 




Per Cent. 


Per Cent. 


Per Cent. 


Per Cent. 


Per Cent. 


Per Cent. 


Per Cent 


Fat ... . 


. 5.16 


4.88 


4.84 


4.37 


4.11 


3.82 


3.80 


Milk-sugar . 


. 5.68 


6.20 


6.10 


6 30 


5.90 


5.70 


6.15 


Proteids . , 


. 4.14 


3.71 


4.17 


3.27 


3.71 


1.08 


3.53 


Ash ... . 


. 0.17 


0.19 


0.19 


0.16 


0.21 


0.20 


0.20 


Total solids . 


. 15.15 


14.98 


15.30 


14.10 


13.93 


10.80 


13.68 


Water . . . 


. . 84.85 


85.02 


84.70 


85.90 


86.07 


89.20 


86.32 




100.00 


100.00 


100.00 


100.00 


100.00 


100.00 


100.00 



180 







PEDIATRICS. 












TABLE 41.— Continued. 










VIII. 


IX. 


X. 


XI. 


XII. 


XIII. 


XIV. 




Per Cent. 


Per Cent. 


Per Cent. 


Per Cent. 


Per Cent. 


Per Cent. 


Per Cent. 


Fat 


. 3.76 


3.30 


3.16 


2.96 


2.36 


2.09 


2.02 


Milk-sugar . . 


. 6.95 


7.30 


7.20 


5.78 


7.10 


6.70 


6.55 


Proteids . . . 


. 2.04 


3.07 


1.65 


1.91 


2.20 


1.38 


2.12 


Ash 


. 0.14 
. 12.89 


0.12 
13.79 


0.21 
12.22 


0.12 


0.16 
11.82 


0.15 
10.32 


0.15 


Total solids . . 


10.77 


10.84 


Water .... 


. 87.11 


86.21 


87.78 


89.23 


88.18 


89.68 


89.16 



100.00 100.00 100.00 100.00 100.00 100.00 100.00 



All these specimens of milk were obtained from healthy mothers, and in 
every case the infant was thriving. In a number of these cases, however, 
when one of the infants which was doing well on its own mother's milk was 
fed with one of the other combinations, it soon became sick, and had to be 
changed back to the one adapted to its digestion. Human milk may, then, 
be considered to represent not an especial food but a combination of foods, 
and its fat, sugar, proteids, and ash to represent these different foods. In 
other words, we find by experience that the digestive capabilities of infants 
differ, just as do those of adults, and that nature provides a number of 
varieties of good human milk adapted to the varying idiosyncrasies of infants. 

Bacteriological Examination. — Although human milk is usually 
considered to be sterile, except in some cases in which the woman is diseased, 
yet Cohn and Neumann have examined the milk of forty-eight healthy 
women and have found bacteria in forty-three cases. These organisms 
were mostly represented by the staphylococcus pyogenes albus, with a few of 
the staphylococcus pyogenes aureus and the streptococcus pyogenes. They 
found fewer bacteria when the breast had been emptied a short time pre- 
viously, and more when there had been a stagnation of the milk in the breast. 
More bacteria were also found in the first few drops than in the last ones, and 
from their experiments they concluded that the bacteria enter the nipple 
from without. The conclusions deduced from their experiments, as well as 
from the experiments of others who have met with similar results, seem to 
show practically that bacteria can enter the ducts of the nipple and penetrate 
to a greater or less distance ; also that the milk in its course from the gland 
to the nipple washes out the bacteria, and that we can in this way account 
for the presence of these organisms in the milk which is first drawn from 
the breast, and their absence from that which comes later. 

Young animals at birth begin to receive their nourishment immediately, 
and a corresponding increase in their weight takes place from the first day 
of life. The human infant in like manner should begin with its nursing 
early, getting what it can from the breast until the full supply of milk has 
come. In this way it will not be so likely to haVe a large initial loss of 
weight to regain, a condition by which it is often handicapped at the very 
beginning of its career, when there is most danger to be apprehended from a 
depression of its vitality. Every day, every hour, is of the utmost importance 



FEEDING. 181 

in the earlv days of life, and, provided it can be done without detriment to the 
condition of the mother, the sooner the infant is put to the breast the better 
it will be. Under exceptionally favorable circumstances, as I have already 
told you, we see the breast-fed infant steadily gaining in weight during the 
first year of its life (Lecture IV., page 103). Ordinarily, however, we find 
this uniform increase in weight, which I have just indicated to you in 
speaking of the infant at the breast (Case 61, page 160), to be interrupted 
from time to time by various causes. These may arise during the dental 
period, in vaccination, from some temporary trouble arising in the breast of 
the mother, or from a combination of circumstances which may prevent the 
infant from receiving the proper qualitative elements in its food, or from 
obtaining a sufficient quantity. This continual increase in weight is of the 
greatest importance in the first year, as it is the chief index by which we 
note the progress of nutrition in the infant and the normal condition of the 
milk. During the first twelve hours of life, and in most cases during the 
first t^^enty-four to thirty-six hours, owing to the inability of the mother 
to supply milk for her infant, scarcely any food is, as a rule, obtained. If 
during this period the infant is restless and evidently hungry, 5 to 10 c.c. 
(1 to 2 drachms) of a sugar solution may be given at intervals of two or 
three hours. This solution should be made by dissolving milk-sugar in 
sterilized water, and its strength should be from five to six per cent. If the 
mother's milk is delayed still longer, something additional must be given to 
the infant, and if the food can be obtained from a milk-laboratory, I should 
order the following prescription : 

Prescription 3. 

Fat 1.00 

Sugar 5.00 

Proteids 0.75 

Eeaotion slightly alkaline. 
10 feedings, each 30 c.c. (1 ounce). To be heated for thirty minutes at 75° C. (167° P.). 

AYhere the infant's food has to be prepared at home, these proportions 
of fat, sugar, and proteids can be obtained, as I shall explain to you later 
(Lecture X., page 279), in my lecture on the home modification of milk. 

The younger the infant the greater the metabolic activity, and hence the 
greater need of frequent feeding, for food is required not only for repair of 
waste, but also for the infant's rapid proportionate growth. This, with the 
increased demand for additional animal heat, makes essential the regulation 
of the intervals of feeding according to the a^e. 

o o c? 

Intervals of Feeding. — The intervals constitute a very important 
part of the management of breast feeding, where, as I have told you, the 
quantity is regulated by the breast itself. These intervals should be defi- 
nitely stated to the mother at different times throughout the nursing period, 
and should be adhered to. I have represented in this table (Table 42) the 
intervals which should be recommended. You must, however, understand 



182 PEDIATRICS. 

that these are only average rules, and that the intervals of feeding should be 
made to correspond to the stage of development of the individual. 

TABLE 42. 

The day feedings are supposed to begin with the 6 A.M. feeding and to end with the 10 P.M. 

feeding. 



Number of 
Night Feedings. 



Number of 
Age. Intervals. Feedings in 

24 hours. 

2 hours 10 1 

2 " 9 1 

2J " 8 1 

2J " 7 . 

3 " 6 

3 '' . . 5 



om birth to 4 weeks 

4 to 6 '' 

6 to 8 " 

2 to 4 months 

4 to 10 " 

10 to 12 " 



When the milk has begun to be produced in the breast, the infant should 
be fed once in two hours during the day and once during the night until it 
is six weeks old. The day feedings are usually reckoned from 6 A.M. to 
10 P.M. This interval of two hours should be adhered to, allowing that 
exceptional circumstances may arise where the physician must judge accord- 
ing to the individual case, until the sixth or eighth week is reached, when 
the intervals may be made two and one-half hours, and the number of 
feedings in the twenty-four hours eight. At about the fourth month the 
intervals can be made three hours, and the number of feedings six. When 
the infant is two or three months old, the night feeding can be omitted. 
The number of feedings at ten months may be reduced to five. Allowing 
the mother to have as many hours of continuous sleep at night as possible 
is especially important, in order that she may not be exhausted by the lack 
of that regular and sufficient rest which is of the utmost necessity for the 
production of a normal milk. 

Irregularity in nursing, too frequent nursing, and too prolonged intervals 
often so disturb the quality of human milk as to transform a perfectly good 
milk into one entirely unfitted for the infant's powers of digestion. Thus, 
as I have previously explained to you, too frequent nursing lessens the 
water and increases the total solids in human milk, making it resemble in 
a certain way condensed milk ; while too prolonged intervals result in such a 
decrease of the total solids as to render an otherwise good milk too watery 
and unfit for purposes of nutrition, however well it may be digested. I 
repeat, then, that the lesson that may be drawn from these facts is that 
some general rule for the feeding intervals should not only be recommended 
but enforced. The mother should neither injure her infant's digestion by 
nursing it too frequently, and thus giving it a too concentrated fluid, nor, by 
neglecting to feed it often enough, interfere with its nutrition by giving it a 
food that is too diluted. 

Regimen of Lactation. Diet. — The diet of the nursing mother 
should not essentially differ from what would be considered to be a healthy 
one for her at any time. There is no special diet which, under all circum- 



FEEDING. 183 

stances, is best for' all nursing women during the period of their lactation. 
In the early days of the puerperium there is, as a rule, more danger of over- 
feeding than of underfeeding the mother. The tendency, in my opinion, 
is to give too much meat and solid food, with the result that when the secre- 
tion of the milk is being established the total solids are increased to a degree 
beyond the capacity of the still undeveloped digestive function of the infant. 
I have usually found that infants in the early days and weeks of life thrive 
better on a milk that shows a high percentage of water in proportion to 
that of the total solids. A rule which has in my experience become almost 
an axiom is that the age of the individual infant is in inverse proportion 
to its powers of absorbing solid food, and in direct proportion to the need 
of a large amount of water in its food. A light and plentiful diet should 
therefore be given to the mother while she is confined to her bed. This 
diet should consist of milk, gruels, soups, vegetables, bread and butter, and 
after the first week a small amount of meat once during the twenty-four 
hours. When the mother is able to go out of the house again, and has 
resumed her usual habits, the quality of the diet can be very much 
increased, and she can have the usual variety of food represented by meats, 
vegetables, milk, fruits, and cereals. There are no special kinds of food 
which are contra-indicated, provided we keep the food within the limits of 
the ordinary articles which commonly represent a plain but nutritious diet. 
It is very important for the nursing mother to have her meals at regular 
intervals, and during the early part of the lactation to take food somewhat 
more frequently than when she is not nursing. The additional meals, as a 
rule, should be made up of milk or cocoa. I have not seen the advantage 
of adding any special beverages, such as beer, malt, or stimulants, to her 
diet. She should receive as much milk as is compatible with her digestion, 
and should drink a plentiful supply before retiring at night. I have recom- 
mended this wide range of food for the nursing mother with a purpose, — 
namely, that it seems necessary to counteract many erroneous ideas and 
false views which are held on this subject. In my experience I have fre- 
quently met with mothers who were being deprived of the very articles 
which would in their special case have tended to aid in the production of 
good milk for their infants. The food of the nursing woman is without 
doubt closely connected with that which she provides for her infant. I have 
already spoken of the possibility of the elimination of various substances 
by the mammary gland, and we should therefore impress upon mothers the 
importance of a carefully arranged diet when they are nursing. Certain 
vegetables, and sometimes fish, will in individual cases affect the milk and 
cause discomfort to the infant. We must, then, in every case, seek to deter- 
mine which article of diet may cause disturbance in the special woman's 
milk secretion, and eliminate that article. We should, however, be very 
careful not to prohibit this special article of diet from the regimen of a large 
number of women to whom it might be of benefit rather than of harm, 
simply because it has affected the milk of a few women. For the average 



184 PEDIATRICS. 

woman a plain mixed diet, with a moderate excess of fluids and proteids over 
what she is normally accustomed to, will, as a rule, give the best results. 

Exercise. — Exercise has so constant an influence on the changes which 
take place in the daily secretion of the milk, that the mother should be 
encouraged to be out of bed and to walk about her room as soon after 
her confinement as is possible without injuring her physical condition. 
Exercise is so important for promoting the proper elaboration and equi- 
librium of the milk secretion during the entire period of lactation, that it 
should always be insisted upon, and regular hours for walking should be as 
definitely arranged during the day as the hours for eating. The exercise 
must, however, be in accordance with the strength of the special woman, for 
fatigue has the same deleterious influence on the production of the milk as 
has lack of exercise. 

Disturbed Lactation. — The disturbances which are liable to occur in 
the course of lactation are frequent and varied. They should be studied 
carefully and recognized at once when they occur, or the continuation of the 
lactation may not only be interfered with but be prevented entirely. When 
discussing the significance of the appearance of colostrum corpuscles in 
human milk (Lecture VII., page 166), I dwelt so fully on the variations which 
are coincident with this appearance, that I shall now merely refer to them as 
among the possibilities of a disturbed lactation. When they are found after 
the first two weeks of life the milk should be looked upon with distrust, and 
special efforts should be made to discover their cause, and to prevent the 
dangers which are liable under these circumstances to arise. These dangers 
may be not only from combinations of the milk elements which are incom- 
patible with the infant's digestion, but also from the disturbances which may 
arise from the free mammary elimination of foreign material, which I have 
already referred to. 

Drugs. — We know that during periods of mammary disturbance there 
is a much greater possibility, than when the gland is in a normal condition, 
of the direct transudation from the blood of such inorganic substances as 
arsenic, antimony, lead, iodide of potash, mercury, and others, taken by the 
mother. Well-authenticated cases come to our notice from time to time 
where injury has been done to the nursing infant in this way, and where 
even death has occurred from the elimination by the breast-milk of certain 
organic substances, such as colchicum and morphine. 

The greatest variety of substances have been found in the milk, but no 
definite rule as to the amount of this elimination has yet been established, so 
that our knowledge of the existence of this process is valuable as a prophy- 
lactic against harm, rather than as a means of direct benefit to the infant in 
disease, which latter point I shall not discuss except to call attention to 
the fact that the medicinal treatment of infantile disease through the breast- 
milk is exceedingly inexact. 

We must also recognize the clinical fact that this elimination may occur 
at any time during the nursing period in the breasts of women who, so far 



FEEDING. 185 

as we can ascertain, are in a perfectly healthy condition. Thus, every prac- 
titioner has at times doubtless observed the laxative effect on the mfant of 
such drugs as compound liquorice powder given to the mother ; and a case 
has lately come to my notice where an infant vomited for weeks while taking 
the milk from the breast of its mother, who was unusually well and strong, 
but who was in the habit of drinking a considerable quantity of porter daily. 
After the porter was omitted the vomiting ceased at once, and did not return. 

These facts warn us that the use of drugs during the period of lactation 
should be far more limited than at other times. Saline cathartics may not 
only act unfavorably on the infant through the mammary excretion, but 
may lessen very decidedly the flow of the milk, and even stop it altogether. 

Menstruation. — We must next consider the question of the variation 
in the milk which takes place from natural causes, such as the return of 
menstruation. Does such a return necessarily contra-indicate the continua- 
tion of nursing? As in all questions of this kind, we cannot adopt and 
follow an inflexible rule, but must be guided by what seems best for the 
individual case. Infants are at times affected so seriously by the alteration 
in the constituents of the milk which occurs once in four weeks that their 
nutrition is markedly interfered with, and a change to a more stable food is 
indicated. Again, the only disturbance which may arise is a temporary and 
slight digestive attack for a day or two, which apparently does not mate- 
rially affect the infant, and makes us hesitate to run the risk of depriving 
it of a food on which it thrives during twenty-six days out of twenty-eight. 
We must also not be too hasty in concluding from the bad symptoms in 
the infant that we should at once withdraw it permanently from the breast, 
for the catamenia may appear once, and then not again for a number of 
months, the infant's powers of digestion in the mean time becoming so 
much more fully developed that they are unaffected by the milk of the 
catamenial period. Even where the catamenia recur regularly, the disturb- 
ance which may have been great at one period may for many reasons fail 
to recur at the next ; so that the question is reduced to whether the compo- 
sition of the milk shows a recovery of the equilibrium of its constituents 
within a few days, or remains affected to such a degree as to endanger the 
integrity of the infant's nutrition. 

My own experience is in favor of allowing the infant to continue with 
the breast, unless it is decidedly contra-indicated by circumstances such as 
have just been mentioned. 

I have seldom met cases which could not without permanent injury be 
tided over the small amount of temporary digestive disturbance which may 
arise. Within a few days I have seen a case where the return of the cata- 
menia produced no effect whatever on the infant ; and this is only an instance 
of what in all probability often occurs where mother and infant are at the 
time in an otherwise normal condition. There have, as yet, been too tew 
analyses made during the catamenial period to justify us in drawing any 
definite conclusions as to the chemical status of the question ; but the proba- 



186 PEDIATKICS. 

bility is that the milk will be found to be deficient in fat and to have its 
proteids increased, following the general rule of disturbed mammary secre- 
tion, and that consequently it is in a condition to interfere temporarily with 
both digestion and nutrition. 

Pregnancy. — A much more serious question arises when the nursing 
mother becomes pregnant ; for here the almost universal clinical experience 
is that the infant, for various reasons, cannot continue to be fed by its 
mother, it being unusual for a woman to have sufficient vitality to nourish 
properly her living child and growing foetus. The danger of reflex miscar- 
riage from the continual irritation of the mammary gland by nursing I 
personally have had no experience with, but this is mentioned as one of the 
dangers contra-indicating the continuation of nursing by a pregnant woman. 
We must, however, here also not judge hastily, but take all the circum- 
stances of the case into consideration before deciding on a measure of such 
vital importance to both child and foetus. If the mother remains strong 
and vigorous, and the analysis of her milk shows no deterioration, while 
the infant is a delicate one just beginning to thrive on its rightful supply of 
natural food, or if it is during a hot period of the year, and especially 
where a wet-nurse or feeding from a milk-laboratory cannot be employed, it 
will often be wisest to take some risk and continue the nursing for a certain 
time, perhaps six or eight weeks, and then, according to circumstances, 
gradually to substitute another food. Almost every case will differ in the 
questions to be decided, and must be judged on its own indications and 
contra-indications, always, however, recognizing the accepted rule that lac- 
tation and pregnancy are usually incompatible. 

The nursing mother is inclined to believe that if she feels well and 
strong her milk must be good for her infant under all circumstances. She 
therefore frequently transgresses the rules which are necessary for keeping 
her milk in equilibrium, and she should be made to understand that some- 
times abnormal variations are liable to arise, however good her general 
health may be. She is simply fulfilling a task demanded by nature from 
those who bear children, and her duty, when once she has undertaken to 
nurse, is to prevent as much as possible these variations by regulating her 
life to a normal standard and avoiding excitement. Both of these requisites 
of a normal lactation come within the province of the physician to explain 
as he would any other branch of rational medicine. He should impress 
upon her that emotional mothers do not make good nurses, and that the 
physiological influence of the emotions on the nervous system, with its re- 
sulting changes in the mammary secretion, has necessarily a much wider 
range in women who are subjected to the customs and vicissitudes of modern 
life than it has in those who live in a more natural way. 

Having shown you in Table 41 the great variations which occur in the 
percentages of the elements of human milk, I will now endeavor to explain 
to you by means of another table (Table 43) the percentages and combina- 
tions which you will be likely to meet with in abnormal milk. 



FEEDING. 187 



TABLE 43. 



Showing typical analyses of a normal, a poor ^ an over-rich, and a had human 

breast-milk. 

Normal Milk. Over-rich Milk. ^ , Afiv 

(Healthy life Poor Milk. (Rich feeding ; ^^ ^^'^'■^^ 

as to exercise (Starvation.) lack of exer- 1. 7\ 

-,.-,. . . Disease, etc. ) 

and food.) cise.) ' 

Fat 4 1.10 5.10 0.80 

Sugar 7 4.00 7.50 5.00 

Proteids 1.50 2.50 3.50 4.50 

Ash 0.15 0.09 0.20 0.09 

Total solids 12.65 7.69 16.80 10.39 

Water 87.35 92.31 83.70 89.61 

100.00 100.00 100.00 100.00 

The terms poor and bad milk are merely relative^ and in common use 
do not have a definite meaning. I shall, therefore, explain the distinc- 
tion which I make between them. I have adopted the terms for the pur- 
pose of simplicity and to distinguish a milk which can be restored easily to 
a normal condition from one where the difficulty of such restoration is very 
great. By a poor milk I mean one which represents a condition of lack of 
nourishment or starvation in the mother, but one which can easily be changed 
by the proper feeding of the mother. In this case the normal mechanism of 
the mammary gland has not been interfered with. By a bad milk I mean 
one which represents a profound disturbance of the mechanism of the mam- 
mary gland produced by many causes, disease, pregnancy, and especially 
extreme nervous conditions in the mother, and one which cannot be easily 
changed to a good milk. 

I shall now show you a table (Table 44) in which I have condensed the 
many means which you will have to make use of in managing the most dif- 
ficult question which we meet with in the treatment of infants. 

TABLE 44. 

General Principles for Gfuidance in managing a Disturbed Lactation. 

To increase the total quantity Increase proportionately the liquids in the 

mother's diet, and encourage her to believe 

that she will be enabled to nurse her infant. 

To decrease the total quantity Decrease proportionately the liquids in the 

(Barely necessary.) mother's diet. 

To increase the total solids Shorten the nursing intervals ; decrease the 

exercise ; decrease the proportion of liquids 

in the mother's diet 
To decrease the total solids Prolong the nursing intervals ; increase the 

exercise ; increase the proportion of liquids 

in the mother's diet. 

To increase the fat Increase the proportion of meat in the diet. 

To decrease the fat Decrease the proportion of meat in the diet. 

To increase the proteids Decrease the exercise. 

(Very rarely indicated.) 
To decrease the proteids Increase the exercise up to the limit of fatigue 

for the individual. 



188 PEDIATRICS. 

In attempting to formulate these rules I must warn you that I am dealing 
with a subject of which very little is known definitely. I can, therefore, 
at present only state my experience in a large number of cases, and give 
you some general idea of how you are to recognize whether you are dealing 
with a bad or poor milk rather than with a normal variation of a good 
milk. This knowledge, however, of the variations which take place in 
human milk is of the utmost clinical importance during the period of lacta- 
tion, for it is the only means by which we can decide definitely and intelli- 
gently many vital questions in this period. 

The Management of Disturbed Lactation. — Instances have con- 
tinually been brought to my notice where infants have been allowed either 
to continue with their mothers' milk when they were not thriving on it, 
simply because it was mother's milk, or, on the other hand, have been 
weaned from their mothers for what would evidently have been insufficient 
reasons had the case been thoroughly understood. In both instances a 
proper knowledge of what can be done with human milk — that is, with the 
management of its different constituents by increasing or decreasing their 
relative proportions — would have been of benefit to both mother and child, 
and in some cases would have saved the life of the latter. This lack of 
knowledge, or, I should say, lack of adaptation of the knowledge which we 
possess of this branch of medicine, is, to say the least, reprehensible, and in 
other branches of our art, which are more intelligently and carefully studied, 
would be deemed inexcusable. Physicians are continually stating to their 
patients that human breast-milk is the best food for infants, and at the 
same time are content to ignore the very principles which would make 
their statements true. We should understand that when we speak of the 
superiority of breast-milk as a food, we mean good average breast-milk and 
for the average infant. 

In all these cases of disturbed lactation we must first determine whether 
the symptoms in the infant are really caused by a disturbance of the milk- 
supply. We ascertain first whether the supply of milk is sufficient in quan- 
tity by the methods which I have already described to you. We then in- 
vestigate the quality of the milk. A chemical analysis shows us whether 
the percentages of the different elements are (1) normal or (2) abnormal. 
If we find them to be normal, we know that it is not the milk which is 
disturbing the infant, and we must seek for the cause of the disturbance 
in other sources beyond the breast. If we find the percentages to differ de- 
cidedly from those of average human milk, we must determine whether it 
is the variation from the normal average percentage which is producing the 
trouble, or whether these percentages are really well adapted to the infant 
and the cause of the trouble is to be looked for elsewhere. This can be 
done only by changing the different percentages and watching the result. 
If we find them abnormal, we can usually determine whether it is one or 
several of the elements which are producing unfavorable symptoms, and we 
should endeavor by our treatment to change the percentages of these ele- 



FEEDING. 189 

ments so as to correspond first to the normal average percentages, and then, 
if this is not sufficient, to reduce them to lower percentages than the average 
until the infant's digestive functions have recovered their equilibrium. We 
must not forget in applying these principles that the cause of the disturb- 
ance of the milk exists in some abnormal condition of the mother, whether 
physiological or pathological, and that we must first remove this cause or 
we shall fail to regulate the milk. 

A sedentary life, with abundance of rich, mixed food, provided the 
woman has a strong, healthy digestion, appears to increase the total solids 
and to decrease the water. This increase is almost always in the fats 
and proteids rather than in the sugar and ash ; in fact, the marked vari- 
ations in human milk are almost always shown in the fat and proteids, 
and hence our attention must almost invariably be directed to correcting 
these elements. This is fortunate, as we know of no special treatment, 
except on very general principles, by which we can alter the proportion 
of sugar or salts to the other constituents. A meat, or rather a nitro- 
genous, diet in the woman increases the fat in her milk. Our physiological 
knowledge also indicates that much fat eaten by the woman tends rather 
to lessen the fat in her milk. Hence to increase the proportion of fat in 
a woman's milk we should give much meat and only a moderate amount 
of fat. The proteids are more difficult to deal with. They have a ten- 
dency to increase in very bad and in very rich milk. The problem which 
we have to solve is almost always how to decrease them, no matter what 
the milk is. Our knowledge, unfortunately, concerning a sure means of 
reducing the proteids is very limited. Practically, however, I have found 
that where the woman is in good health it is physical exercise which we 
must insist upon, preferably walking in the open air and within the limits 
of fatigue. A walk of from one to two miles twice daily I have found 
to be about what the average healthy woman in New England needs to 
reduce the percentage of the proteids in her milk ; but the amount of exer- 
cise must be carefully regulated according to the physical capabilities of 
the individual. 

Bearing in mind these simple rules, and having determined, by means 
of an analysis or analyses, the cause of the special disturbance, you will be 
able to regulate the nursing period in cases where a lack of this knowledge 
would often necessitate weaning. You may in this way also avoid serious 
harm to the infant. 

I shall next call your attention to these illustrative tables, which still 
further explain the rules I have just given you. I shall presently describe 
in detail some of these cases and discuss tlieir analyses, but this repetition 
I deem advisable, as the subject is both important and difficult. For the 
purpose of still greater clearness I have in each of these tables first rocordcMi 
the analysis of a normal milk, and have then, in parallel columns, shown 
the abnormal percentages and the changes produced in them by the manage- 
ment of the mammae. 



190 



PEDIATRICS. 



TABLE 45. 

(Human Milk.) 
Showing the wfiuenee of a luxurious life on a poorly fed hut healthy wet-^urse. 



Normal. 

Fat 4.00 

Sugar 7.00 

Proteids 1.50 

Ash 0.15 

Total solids 12.65 

Water 87.35 

100.00 



II. 


III. 


IV. 


Two days 
before 
change 
of food. 


Rich food 
and but 
little ex- 
ercise for 
a month. 


Food and 
exercise 
regulated. 


0.72 


5 44 


5.50 


6.75 


6.25 


6.60 


2.53 


4.61 


2.90 


0.22 


0.20 


0.14 


10.22 


16.50 


15.14 


89.78 


83.50 


84.86 



100.00 



100.00 



100.00 



TABLE 46. 

[Human Milk.) 

Showing a had milk and one which it was impossible to manage on account of the continual 
recurrence of the same cause, uncontrolled emotions. 

Emotions causing dis- 
Normal. turbance in infant's 
digestion. 

Eat • 4.00 0.62 

Sugar 7.00 5.80 

Proteids 1.50 4.21 

Ash 0.15 0.20 

Total solids 12.65 10.83 

Water 87.35 89.17 

100.00 100.00 • 

TABLE 47. 

{Hum,an Milk.) 

Showing a milk possible to manage, because the mother, though excitable, was able and 
willing to control her emotio7is. 

Infant doing badly. Infant doing well. Wet-nurse pro- 
Normal. Colic. Mother be- Mother after vided but not 
fore treatment. treatment. used. 

Fat 4.00 1.62 3.20 3.04 

Sugar 7.00 6.10 6.40 6.60 

Proteids .... 1.50 3.54 2.52 2.32 

Ash 0.15 0.17 0.18 0.12 

Total solids. . . 12.65 11.43 12.30 12.08 

Water 87.35 88.57 87.70 87.92 

100.00 100.00 100.00 100.00 

In the above case the mother was very nervous and wished to nurse her 
infant, but thought that she could not, as she had been discouraged by her 
nurse and physician. 

She was then told that she could nurse in a week, if in the mean time 
she took proper food and exercise and withdrew the infant from the breast. 
This she did, and had her breasts regularly pumped, wdth good results. 



FEEDING. 



191 



TABLE 48. 

{Human Milk.) 

Showing the effect of the catamenia on human milk. 

Normal Catamenia, Seven Days after 

Second Day. Catamenia. 

Fat 4.00 1.37 2.02 

Sugar ..... 7.00 6.10 6.55 

Proteids .... 1.50 2.78 2.12 

Ash 0.15 0.15 0.15 

Total solids. . . 12.65 10.40 10.84 

Water 87.35 89.60 89.16 

•100.00 100.00 100.00 



Forty Days after 
Catamenia. 
2.74 
6.35 
0.98 
0.14 



10.21 

89.79 

100.00 



TABLE 49. 

{Hum,an Milk.) 
Showing a milk in which the proteids, which were disturbing the infant, could not he re- 
duced until the mother was made to walk comfortably, and thus without fatigue. 

Infant as before. 



Normal. 



Fat 4.00 

Sugar 7.00 

Proteids .... 1.50 

Ash 0.15 

Total solids. . . 12.65 

Water 87.35 



100.00 



Infant with, colic 
and vomiting. 
Mother taking 
no exercise and 
very rich food. 

3.05 

6.10 

3.89 

0.16 

13.20 

86.80 

100.00 



Mother walking 
two miles daily, 
but having blis- 
ters from French 
shoes. 

0.65 

5.25 

8.82 

0.18 



9.90 

90.10 

100.00 



Infant doing weU. 
Mother walking 
two miles. Easy 
shoes, no blis- 
ters. 

3.34 
6.30 
2.61 
0.16 



12.41 

87.59 
100.00 



TABLE 50. 

{Hum,an Milk.) 
Showing how a milk can be managed while the ymrsing is continued. 
Infant two weeks 





Normal. 


old, with serious 
general nervous 
symptoms and 
pain. Mother 
eating much 


Mother walking 
and eating less 
meat. Infant 
entirely weU. 


Infant four 
months old, with 
pain and diar- 
rhoea. Mother 
not walking so 


Infant doing well. 
Mother walking 
two miles daily. 
Milk diluted 






meat and taking 




much. 










no exercise. 










Fat ... . 


4.00 


3.44 


2.09 


3.98 




3.19 


Sugar . , . 


. 7.00 


5.60 


6.70 


7.00 




5.60 


Proteids . 


1.50 


3.96 


1.38 


2.22 




1.78 


Ash ... 


0.15 


0.20 


0.15 


0.19 




0.16 


Total solids . 


12.65 


13.20 


10.32 


13.39 




10.73 


Water . . 


87.35 


86.80 


89.68 


86.61 




89.27 



100.00 



100.00 



100 00 



100.00 



100.00 



As is seen from the analyses in Table 50, the infant did not do well 
until the mother began to exercise, and at four months it was again alfected 
by apparently the high percentage of the proteids. The infant was con- 
siderably under the weight corresponding to that of the average infant of 



192 



PEDIATRICS. 



four months. It was found to nurse twenty-five minutes at a time^ and by 
calculation from its weight before and after nursing, it was found to take 
from 80 to 120 c.c. (20 to 30 drachms). This amount being larger than 
the probable size of its stomach demanded, the time of the nursing Avas 
reduced to twenty minutes, and 20 c.c. (5 drachms) of sterilized water were 
given in the middle of the nursing, thus changing the percentages in the 
milk to the figures which are represented in the last column. This calcula- 
tion is on the basis of 100 c.c. (25 drachms) to each nursing. 

So long as this method of feeding was adhered to, the infant did well. 
It was evidently a case where the infant could not digest over two per 
cent, of proteids. 

TABLE 51. 
{Hmnaii Milk.) 

Showing that even for a long interval the breasts may he i'>wn]ped and the result he a 

successful nursing. 



Fat . . . 
Sugar . . 
Proteids . 
Ash . . . 
Total solids 
Water . . . 





Infant st 


lowing nervous 


Infant showing no uric 




symptoms and 


much 


acid and thriving. 


Normal. 


uric 


acid. 


Mother 


Mother walking two 




taking 


no exercise 


miles and not eating 




and much rich food. 


much meat. 


4.00 




5.71 




2.67 


7.00 




4.00 




6.60 


1.50 




4.29 




3.18 


0.15 




0.19 




0.17 


12.65 




14.19 




12.62 


87.35 




85.81 




87.38 



100.00 



100.00 



100.00 



In this case the infant was withdrawn from the breast temporarily, and 
the breasts pumped for twenty-seven days. 

When the analysis presented the figures seen in the last column, the 
milk was treated by diluting it, as in the previous case, and the infant was 
put back to the breast. 

TABLE 52. 

[Human Milk.) 

Showing the value of retaining the hreast-milk hy ma^iaging even an unpromising case. 







Infant with colic 
















and failing. 


Infant put 


on 












Mother no ex- 


bottle. Breasts 












ercise, nursing 
irregularly, 
irregular and 


pumped every 
four hours. 


Exercise in- 
creased to two 


Eating much 




Normal. 


Moderate 


ex- 


miles. Small 


meat. Exer- 






improper 
sweet food. 


e r c i s e,— 
mile. F 


one 
ull 


amount 
meat. 


ot 


cise the same. 






Nervous, wor- 


regular ( 


liet. 












ried condition. 


Tranquil. 










Fat . . . . 


4.00 


0.34 


3.24 




2.79 




4.84 


Sugar . . . 


7.00 


5.40 


5.45 




5.05 




6.00 


Proteids . . 


1.50 


3.61 


3.95 




3.66 




8.42 


Ash. . . . 


0.15 


0.18 


0.16 




0.20 




0.17 


Total solids. 


12.65 


9.53 


12.80 




11.70 




14 43 


Water. . . 


87.85 


90.47 


87.20 




88.30 




85.57 



100.00 



100.00 



100.00 



100.00 



100.00 



FEEDING. 193 

The above represents a bad milk from the failure of the healthy mother 
to conform to the rules of lactation. This bad milk, represented in the sec- 
ond column, had to be made into a rich milk by regular feeding before any 
attempt could be made to alter the ratio of the constituents. The proteids 
were then reduced somewhat by exercise, and, after the breasts had been 
pumped for two weeks, the analysis showed the percentages as represented 
in the last column. The milk was then diluted with sterilized water by 
the same method as was explained in Table 50, and the infant was put to 
the breast and did well ; in fact, was carried through an attack of retro- 
pharyngeal abscess with this breast-milk. 

If you have carefully studied these tables (Tables 43, 45, 46, 47, 48, 49, 
50, 51, 52) and the principles (Table 44) on which they are based, you can 
appreciate the importance of the interesting illustrative cases which I am 
about to describe to you. I have selected them from a large number of my 
patients because they represented so well the value of a knowledge which aids 
us in the management of human milk during periods of disturbed lactation. 
The decrease in the total quantity of the milk is of ordinary occurrence 
at any time during lactation, but it is most common among civilized races at 
about the eighth to the tenth month. When it occurs early in the lactation 
it is very disheartening to the mother if she is desirous of continuing her 
nursing. She becomes fearful that the flow of milk may stop altogether, and 
the nervous influence thus brought to bear on the mammary gland tends 
to increase the disturbance. We should therefore encourage her to believe 
that the milk will return. I have just succeeded in restoring the full quan- 
tity of milk in the mammary glands of a multipara (Case 63) who was very 
anxious to nurse her infant, which was three weeks old and had been digest- 
ing her milk, but had never nursed vigorously, and was not gaining. The 
mother was much discouraged because her milk lessened in quantity so early 
in the lactation, and she was convinced that it would not retm-n. She had 
been taking, without my knoAvledge, a disproportionately small amount of 
fluid in her diet. There was an element in this case which the intelligent 
nurse brought to my notice, — namely, that the infant (Case 64) Avas not vig- 
orous, and when put to the breast sucked feebly and called upon the gland 
for very little milk. Reacting to this lack of stimulus, the gland, although 
in a normal condition, secreted only the small amount demanded by the 
infant, and the milk lessened day by day. Treatment was instituted on the 
supposition that the mammary gland is practically self-regulating as to the 
amount of food which it will elaborate at a given nursing. If it happens 
to be called upon to nourish twins, it will increase the amount of its supply. 
If the infant which is put to it has a small gastric capacity, it will produce 
the amount needed for that capacity. I assured the mother that the milk 
would return, and I treated directly the mammary gland itself An in- 
crease was made in the amount of liquid in the mother's diet, and the 
breasts were, after each nursing, pumped gently, skilfully, and thoroughly. 
The breast-pump supplemented the feeble action of the infant, and when 

13 



194 PEDIATRICS. 

more work was required of the gland it began to produce more milk. The 
increase in the liquid diet supplied the gland with materials to work with, 
and its mechanism ceased to be disturbed by the nervous influence emanating 
from the mother. She became cheerful when she found the milk returning, 
while the infant, now that the milk could be procured more easily, demanded 
more, sucked more vigorously, and thus satisfied the sensitive mechanism of 
the mammae. 

The next case (Case 65) points to the possibility of our being at times 
too hasty in the decision to deprive an infant of its mother^s milk. 

The mother (see Table 47, page 190), a rather delicate primipara, twenty-five years 
of age, was delivered of a boy seven pounds in weight. Within four hours puerperal con- 
vulsions set in, from which she recovered, but was left with albuminuria 0.25 per cent, and 
casts. The latter disappeared in a few days, but the albumin, although somewhat dimin- 
ished, continued ; and the patient, naturally of a calm disposition, was in a highly nervous 
condition, fearing that she could not nurse her infant, but decidedly opposed to having a 
wet-nurse. The milk appeared in considerable quantity on the fifth day, but the infant did 
not thrive, and, although it gained somewhat in weight, was very fretful, slept very little, 
and looked ill, so that the attending physician became alarmed, and after treating it for 
its dyspepsia without much success until it was five weeks old, and finding that there was 
still about 0.25 per cent, of albumin in the mother's urine, decided with me that the breast- 
milk should be withheld until we could determine the cause of the trouble, and an analysis 
(Analysis 9) was accordingly made, with the following result : 

ANALYSIS 9. 

Fat 1.62 

Sugar 6.10 

Proteids 3.54 

Ash 0.17 

Total solids 11.43 

Water 88.57 

100.00 

This analysis suggesting the probability that the large amount of proteids was causing 
the disturbance of digestion, and that the small amount of fat was not sufficient for nutri- 
tion, the attending physician was very anxious to procure a wet-nurse ; but while we were 
endeavoring to get a proper one, we decided to empty the mother's breasts with the breast- 
pump every day, thus relieving her from the worry of attempting to nurse her infant and 
seeing it fail to gain. She also obtained in this way undisturbed nights and a great deal of 
out-door life. The infant was in the mean time placed on a substitute food, which was 
digested very well, and, as it ceased to cry, the mother's mind became tranquil, and the 
albumin in her urine in a few days was reduced to a trace. The treatment was carried out 
for a week, the milk continuing to flow freely, and an analysis (Analysis 10) was then 
made of the mother's milk and also of that of a healthy wet-nurse (Analysis 11) whose 
infant was thriving on its mother's milk. 

ANALYSIS 10. ANALYSIS 11. 

Mother. Wet-Nurse. 

Fat 3.20 3.04 

Sugar 6.40 6.60 

Proteids 2.52 2.32 

Ash 0.18 0.12 

Total solids . 12.30 12.08 

Water 87.70 87.92 

100.00 100.00 



FEEDING. 195 

The two milks "being equally good, it was decided to allow the infant to begin to take 
one nursing daily from its mother, although the proteids were still about one per cent, 
higher than the infant seemed likely to digest ; it was given to its mother, nursed well, 
seemed satisfied, digested its meal without trouble, and at six months is still being nursed 
and is thriving. 

The next case (Case 66) which I shall describe to you illustrates the 
principle that too frequent nursing lessens the water and increases the total 
solids in human milk, making it resemble in a certain way condensed milk. 
It also illustrates what I have stated concerning the two important questions 
to be considered in the management of a normal lactation, — namely, that 
the digestion as well as the nutrition must be regarded. This case is one of 
the numerous instances of the same kind which have come to my notice, and 
also emphasizes the fact that infants are often weaned from the breast where 
there is not the slightest necessity for it. 

The mother, a healthy primipara about twenty-two years old, had nursed her infant for 
six weeks, during which time the infant was fretful, suifered much from colic, and never 
seemed satisfied. There was, however, a continual gain in weight, although the f^cal dis- 
charges showed evidences of the food not being properly digested and were numerous and 
watery. By advice of the attending physician the infant was weaned. The mother came 
to me for advice in regard to placing her infant on a substitute food. On inquiry I found 
that this infant had been nursed almost continuously night and day, with intervals usually 
of only one hour, and it was evident that the frequent nursings had resulted in producing a 
concentrated milk which the infant's gastro-enteric tract was rebelling against and was not 
digesting, although sufficient food was being absorbed to prevent up to this time any inter- 
ference with the general nutrition. This infant, then six weeks of age, was deprived of its 
supply of good human milk in the middle of the summer simply because the important 
matter of changing the intervals had not been thought of as a means of improving the 
milk and relieving the pain and apparent hunger. There seems to be no doubt that if 
the milk in this case had been properly managed it would have agreed perfectly with the 
infant. I would also add in connection with this case that where the digestion is not carried 
on properly the nutrition must soon suffer, and it is only in the early weeks of a disturbed 
digestion that, as a rule, we find the nutrition to be unimpaired. 

The next case (Case 67) is one of a multipara who was under my care at the City 
Hospital, and who up to the time of her entrance had been nursing her infant, which was 
thriving. This patient stated that her milk had always been abundant and of good color 
up to the time when she was separated from her infant, which was twelve hours previously, 
as she had to be away from home for that time. At the end of twelve hours the breast was 
found to be so distended that the breast-pump had to be applied. The milk was drawn with 
great ease, almost flowing of itself, and in considerable quantity, but it no longer resembled 
the milk of the previous nursings which had been at the proper intervals. On the contrary, 
it was clear, with very little color, the total solids were reduced to a minimum, and it no 
longer would have nourished the infant. 

The treatment of this case was of course to pump the breasts every three hours until 
the infant could again be nursed. 

As an illustration of the harm which may come to an infant from the 
percentage of fat in its mother's milk being too high, and also of the means 
to employ either to increase or to decrease the fat in breast-milk, this case 
(Case 68) will be of interest. The mother was a healthy primipara. She 
had plenty of milk, but the infant suffered from colic and had very frequent 
watery dejections. Finding that she was eating a great deal of meat three 



196 PEDIATRICS. 

times daily and not taking much exercise, I naturally supposed from the 
symptoms of the infant and the diet of the mother that an over-percentage 
of fat was one of the elements which were disturbing the lactation, and 
that a high percentage of proteids would also be found. The analysis 
(Analysis 12) proved my supposition to be correct : 

ANALYSIS 12. 
Primipara. — Healthy ; eating much meat; not taking much exercise. 

Fat 4.96 

Sugar 6.60 

Proteids 3.29 

Ash ... 0.17 

I therefore decided to reduce the meat to a minimum, which was done, 
and three days later an analysis gave the following figures : 

ANALYSIS 13. 

Eating little meat. 

Fat 1.73 

Sugar 5.70 

Proteids 3.74 

Ash 0.13 

The milk was found to be lessening in quantity. The infant's dejections 
were less numerous and had more consistency ; but it was not gaining, and 
continued to have pain. In fact, the analysis showed a poor milk, or even 
a bad one, as represented by the usual combination of a low percentage of 
fat and a high percentage of proteids. The woman was consequently made 
to eat a moderate amount of meat, and to exercise more, and three or four 
days later the analysis showed an improvement in the fat : 

ANALYSIS 14. 
Eating ynoderate am,ount of oneat ; taking m^ore exercise. 

Fat 2.42 

Sugar 5.50 

Proteids , 3.55 

Ash ' 0.15 

The infant now began to gain in weight, but continued to have colic, 
as was expected from the high percentage of proteids. The exercise was 
still further increased, and a later analysis showed a decided lessening of the 
proteids, as is seen in this analysis (Analysis 15) : 

ANALYSIS 15. 

Exercise still further increased. 

Fat 2.35 

Sugar 6.25 

Proteids 2.69 

Ash 0.15 



FEEDING. 197 

The infant began to have regular movements, of good consistency, 
and no longer had pain ; it also gained regularly in weight, and, as you see, 
looks well and strong. The mother has regulated her diet, exercise, and 
sleep in accordance with the requirements of her infant, and her milk has 
again become abundant. 

We shall, of course, often fail in our attempts to manage the percentage 
of fat in this way, but this case illustrates exactly the changes which it is 
usually necessary to produce in order to alter a high fat percentage. The 
proteids also being high, I had an over-rich milk to deal with ; taking away 
the fat-producing element reduced the fat to a low percentage; exercise 
reduced the high percentage of proteids, and a combination of sufficient 
meat and exercise finally produced a milk which could be digested. 

This next case (Case 69) is an interesting one, as it illustrates a number 
of points in the management of lactation. A high percentage of the proteids 
was creating the disturbance in the infant, and it was their final reduction 
through treatment that permitted the lactation to go on. 

The mother, a remarkably healthy and vigorous multipara, living in the country, had 
a plentiful supply of milk. Her diet consisted mostly of vegetables, and she did not take 
much exercise. The infant was not thriving, having had continued attacks of colic, with 
frequent vomiting, and it did not gain in weight. The analysis (Analysis 16) showed a bad 
milk, which was contrary to what we should usually expect to find in the milk of a mother 
who was in such perfect health as this one was. 

ANALYSIS 16. 

Fat 0.52 

Sugar 6.80 

Proteids 2.48 

Ash 0-15 

Total solids 9.95 

Water 90.05 

100.00 

The mother was instructed to eat meat and to walk two miles every day. One month 
later, as the infant had not improved, another analysis was made (Analysis 17), which 
showed that the milk was in a worse rather than a better condition. 

ANALYSIS 17. 

Fat 0.45 

Sugar 6.15 

Proteids 2.47 

Ash 0.16 

Total solids 9.23 

Water 90.77 

100.00 

I found that the mother had eaten meat but once a day, and in small quantity ; 
also that she had not walked much. I then insisted on her eating meat three times a day, 
and walking three miles. This she did for two weeks, when the infant was found to have 
gained slightly in weight, but to still have colic and vomiting. Another analysis (Analysis 
18) showed an increase in the fat. 



198 PEDIATRICS. 

ANALYSIS 18. 

Fat 1.53 

Sugar 6.68 

Proteids 2.48 

Ash 0.16 

Total solids 10.85 

Water 89.15 

100.00 

During the next two months the walking was continued and the meat increased in 
quantity. The infant continued to vomit and have colic until the mother was made to ride 
on horseback every day, when the pain ceased, and from that time the infant gained steadily 
in weight, and was well and strong during the rest of the lactation. An analysis (Analysis 
19) made two and one-half months after this procedure showed that at last the proteids had 
been reduced to come within the limits of the infant's digestion, and that the fat, although 
still having a low percentage, had been increased sufficiently for the infant's nutrition. 
Thus a bad milk was finally changed to a good one. This infant evidently could not digest 
a percentage of proteids approaching 2, but fortunately could be nourished on a low per- 
centage of fat. 

ANALYSIS 19. 

Fat 2.01 

Sugar 6.90 

Proteids 1.54 

Ash 0.17 

Total solids 10.62 

Water 89.38 

100.00 

In the next case (Case 70) I had a poor milk to deal with. The infant 
was four months old. It was perfectly well and was digesting well, but had 
not gained for three weeks. The mother was producing from her breasts a 
sufficient quantity of milk, but the analysis (Analysis 20), as you see, shows 
that this milk had to be modified within the breast by a regulation of the 
diet of the mother : 

ANALYSIS 20. 

Fat 1.29 

Sugar 6.05 

Proteids 2.93 

Ash ■ 0.12 

Total solids 10.89 

Water 89 61 

100.00 

She was consequently made to eat an increased amount of meat, and in 
the course of a few weeks the infant was thriving and gaining in weight. 

The next case (Case 71) is that of a wet-nurse whose infant was digest- 
ing well, gaining in weight, and happened to be of about the same age as 
that of the infant whom she was hired to nurse. In order to see if this 
nurse's milk would agree with the foster-infant, the nurse and her infant 
were brought to the house of the foster-child, and were comfortably lodged 
and plentifully fed. Twenty-four hours later both infants began to have 



FEEDING. 199 

colic and green faecal discharges. An analysis (Analysis 21) of the milk 
showed a high percentage of proteids : 

ANALYSIS 21. 

Fat 3.19 

Sugar 6.40 

Proteids 3.11 

Ash 0.15 

Total solids 12.85 

Water 87.15 

100 00 

The nurse was then given a lighter diet with a greater proportion of 
liquids, and was made to walk one mile twice daily. By weighing the 
infants just before and just after a nursing, it was found that they took 
from 90 to 120 c.c. (3 to 4 oimces) in fifteen minutes. The infants were 
then allowed to nurse for ten minutes. 30 c.c. (1 ounce) of sterilized water 
was next given to them, and they were then allowed to nurse for ten 
minutes longer. In this way I estimated that they were receiving in 
their stomachs 120 c.c. (4 ounces) of food in which the percentage of the 
proteids was under 2.5. The infants ceased to have colic, and the faecal 
discharges became normal. The nurse's infant was then sent away. Two 
weeks later the foster-infant was thriving, and, as another analysis (Analysis 
22) of the milk showed a sufficient reduction of the proteids, the sterilized 

water was omitted. 

ANALYSIS 22. 

Fat 2.87 

Sugar 6.25 

Proteids 2.90 

Ash 0.15 

Total solids 12.17 

Water 87.83 

100.00 

During the rest of the lactation the infant digested well and gained 
fairly in weight. 

This yoimg woman (Case 72), who has brought her infant to show you, 
is perfectly healthy, and is nursing her infant, which has been digesting well 
and steadilv gainino^ in weio^ht for some months. I wish vou to see this 
infant in order that you should understand how at times an infant can thrive 
on what appear to be too high percentages of some of the solids in the milk. 
This is the analysis (Analysis 23) of her milk : 

a:N'ALYSIS 23. 

Fat 4.11 

Sugar .....: 5.90 

Proteids 3.71 

Ash 0.21 

Total solids ....." 13.93 

Water 86.07 

100.00 



200 PEDIATRICS. 

In contrast to this woman (Case 72) is another woman (Case 73) who 
has brought her infant for you to see. The infant is evidently thriving. 
The mother is delicate and frail^ and the infant is being fed by this healthy- 
looking wet-nurse. In the early part of the lactation the infant did not 
thrive, and, as the mother was so delicate, it was not deemed advisable to 
attempt to improve the quality of her milk. The interesting point in con- 
nection with this case is the inability of the infant to digest a poor milk 
and its ability to digest perfectly well this wet-nurse's milk, which in its 
analysis (Analysis 24) shows a very high percentage of fat and of proteids 
and a low percentage of sugar : 

ANALYSIS 24. 

Fat 4.72 

Sugar • 4.55 

Proteids 4.74 

Ash 0.19 

Total solids 14.20 

Water 85.80 

100.00 

This mother who has brought her infant to see me to-day represents a 
case (Case 74) where I entirely failed to change the percentages of the ele- 
ments in the milk. She had a moderate quantity of milk, and nursed her 
infant for two or three months. The infant did not gain, it had colic, and 
at times vomited. The analysis (Analysis 25) showed that it was in the 
class which I have designated as " bad :^' 

ANALYSIS 25. 

Fat 1.61 

Sugar : 4.67 

Proteids 4.07 

Ash 0.17 

Total solids 10.52 

Water 89.48 



100.00 



An increase of meat in this mother's diet and more exercise had no effect 
on the percentages of the elements of her milk, and the infant was therefore 
weaned. Soon after beginning to take a substitute food from the Milk- 
Laboratory the infant ceased to have colic, gained in weight, and it is now, 
as you see, in a healthy condition. The percentages of the elements in the 
substitute food which produced such an immediate change in the infant's 
condition were as represented in this prescription : 

Prescription 4. 

Fat 3.50 

Sugar 7.00 

Proteids 1.00 



FEEDING. 201 

It was merely necessary to raise the percentages of the fat and sugar, and 
reduce that of the proteids, m order to produce this rapid and satisfactory 
result. 

The next analysis (Analysis 26) which I shall show you is that of a 
woman's milk (Case 75), which is instructive for a number of reasons : 

ANALYSIS 26. 

Fat 2.30 

Sugar 6.65 

Proteids 2.57 

Ash 0.12 

Total solids 11.64 

Water 88.36 

100.00 



You see that the percentage of fat is low, and that of the proteids is 
rather high. The infant (Case 76), with the exception of being somewhat 
constipated, was always well, gained in weight, and showed no digestive 
disturbance during the lactation. This was remarkable, as the mother's 
catamenia returned regularly during the lactation from the time that the 
infant was four months old. There was considerable flowing at the 
time of the catamenia, and the mother was habitually constipated and 
did not have a very good appetite. The infant did not seem to be affected 
by any of these conditions. The analysis of this milk was made from a 
specimen of the ^^ middle milk," which was taken between the catamenial 
periods. 

It may be of interest, in connection with what I have said concerning the 
variations in the milk which may arise from emotional causes and menstrua- 
tion, to report the analysis of a milk of a mother and a wet-nurse where 
these influences appeared to produce certain chemical changes. The mother 
(Case 77) (Table 46, page 190), a healthy but rather delicate primipara, the 
period of whose pregnancy had been supervised by me with the greatest care, 
but whose temperament was subject to extremes of despondency and excite- 
ment, was delivered, after a short and easy labor, of a healthy boy (Case 78). 
She was exceedingly anxious to nurse her infant, but within a few hours after 
its birth she was seized with an uncontrollable fear that she would be unable 
to do so. In spite of all the assurances to the contrary which could be 
given to her, and the plentiful supply of milk which in due time came in 
the breasts, she remained in a very nervous, despondent condition. As the 
infant began to show decided signs of indigestion, I thought it best, before 
proceeding further, to investigate the composition of the milk. Tlie analy- 
sis (Analysis 27) resulted as follows, and plainly showed the necessity of 
not persisting further, as it was evidently much altered from unavoidable 
nervous conditions, which seemed likely to recur through the whole of 
her lactation : 



202 PEDIATRICS. 

ANALYSIS 27. 
{Mother's Milk.) 

Fat 0.62 

Sugar 5-80 

Proteids 4.21 

Ash 0.20 

Total solids 10.83 

Water 89.17 

100.00 

Under these circumstances, a healthy wet-nurse (Case 79) (Table 48, 
page 191), whose own infant (Case 80) was strong and thriving, was em- 
ployed, and the foster-infant immediately began to gain in weight and ceased 
to show any digestive disturbance. After a month, however, it was found 
not to have made its weekly gain, to be unusually restless, and to be having 
frequent fsecal discharges. It was then discovered that the wet-nurse was 
menstruating, and on the second day this analysis (Analysis 28) of her milk 

was made : 

ANALYSIS 28. 

( Wet-Nurse.) 

Fat 1.37 

Sugar 6.10 

Proteids 2.78 

Ash 0.15 

Total solids 10.40 

Water 89.60 

100.00 

The catamenia lasted about four days, and did not return for some 
months. The infant after the first twenty-four hours showed no disturbance 
whatever, soon began to gain, and was not affected by the subsequent 
recurrence of the catamenia. This analysis (Analysis 29), made one week 
after the catamenia had ceased, showed a decided change for the better ; that 
is, increased fat and decreased proteids. Forty days after the catamenia a 
still greater improvement was found in the milk, as was anticipated from the 
thriving condition of the infant. The change in the percentages is shown 
in this analysis (Analysis 30). 

ANALYSIS 29. ANALYSIS 30. 

Seven Days Forty Days 

after Ca- after Ca- 

tamenia. tamenia. 

Fat 2.02 2.74 

Sugar 6.55 6.35 

Proteids 2.12 0.98 

Ash 0.15 0.14 

Total solids 10.84 10.21 

Water 89.16 89.79 

100.00 100.00 

The following case (Case 81) is of considerable interest with reference 
to what I have told you in regard to the incompatibility of pregnancy 



FEEDING. 203 

and lactation. Unfortunately, a full consideration of the condition of the 
milk cannot be presented to you, as it rapidly disappeared from the breast 
after the first analysis was made, and, before another specimen could be 
procured, had disappeared entirely. 

The milk was taken from one of my patients who had been pregnant for three months 
and at the same time was nursing an infant (Case 82) nine months old. 

ANALYSTS 31. 

Pat 7.64 

Solids not fat , 6.04 

Total solids 13.68 

The infant at the breast was not thriving. It had been digesting its mother's milk 
perfectly and had been gaining in weight until the pregnancy had existed for some weeks. 
At the time the analysis was made the infant's digestion had evidently been weakened, and 
as a result it had ceased to thrive and was rapidly losing in weight. 

This analysis will be found to illustrate several facts. In the first place, it represents a 
very rich food. The total solids are even greater than appear in most cows' milk, and the fat 
is almost double the percentage which is considered normal in both human and cows' milk. 

It also shows that a food may be unusually high in the percentage of its total solids and 
yet not of a character suited for the nutrition of an infant. The explanation of this fact is 
that although for a time an infant may digest fairly well a rich food, yet that nature has 
provided that the percentages of the elements in its food should remain within certain 
limits. If these limits are transgressed, either by giving too low or too high a percentage 
of any of the solids in the food, the nutrition will be interfered with. In the latter case the 
digestive function of the infant actually becomes weakened, and the strong food soon begins 
to act as a foreign body. The absorption of the food is next interfered with, and the infant 
starves as readily on the strong food which cannot be absorbed as on the weak food in which 
the needed elements are lacking. 

This analysis also represents a condition which, in the majority of cases of pregnancy, 
occurs after the first six or eight weeks, — namely, a much disturbed mammary equilibrium. 
The percentage of fat in proportion to that of the solids not fat is so entirely different from 
the percentages of the different elements in a normal milk that we may say that this milk 
of pregnancy represents a condition of profound disturbance. 

This especial analysis must not be taken as a standard one for the milk of pregnant 
women, for, in all probability, analyses of milk under these conditions differ very widely, 
yet invariably show an absence of the normal percentages. 

This next case (Case 83) (Table 49, page 191) represents a milk which could have been 
changed with comparative ease, provided that the mother had followed the directions given 
to her. She was a multipara, strong and vigorous, with a good appetite and a perfect 
digestion, and her life was entirely free from care. She had a plentiful supply of milk, 
but insisted on eating much more solid food during the puerperium than was compatible 
with keeping the elements of her milk in proper proportions. The infant soon began to 
be restless, and, although it gained in weight, it vomited at times and had colic quite fre- 
quently. An analysis (Analysis 32) of the milk showed what I had expected to find, — 
namely, a percentage of proteids too high for the proteid digestion of the infant. 

ANALYSIS 32. 

Fat 3.03 

Sugar 6.25 

Proteids 3.61 

Ash 012 

Total solids 12.91 

"Water 87.09 

100.00 



204 PEDIATRICS. 

The motlier, who was able to go out of the house, was told to walk two miles twice 
daily. I also ordered her diet to be regulated so that there should be a smaller proportion 
of solids than she was now having. Sterilized water was given to the infant in the middle 
of its nursing. For a few days the infant seemed to improve and was less restless, but in 
another week the symptoms of indigestion returned, and, suspecting that the proper propor- 
tions of the milk were again disturbed, I had another analysis (Analysis 33) made, with the 
following result : 

ANALYSIS 33. 

Fat 3.05 

Sugar 6.10 

Proteids 3.89 

Ash 0.16 

Total solids 13.20 

Water 86.80 

100.00 

The percentage of the proteids, as you see, was now even higher than at the time of the 
last analysis. The mother declared that she had been walking up to the prescribed limits, 
but complained that the exercise tired her very much. It was very evident that the walk- 
ing did not fatigue her sufficiently to influence her milk badly. I found, however, that she 
was not carrying out the rules which I had laid down for her diet, and had eaten freely of 
many rich foods. I then insisted on her leading a more rational life if she was to continue 
her lactation, and she promised that she would. The infant for the next few days ceased to 
have colic and was apparently perfectly comfortable. At the end of another week, however, 
the symptoms of a disturbed digestion returned in the infant, and I had to investigate still 
further the cause of the mammary disturbance. The mother had been carrying out all my 
rules as to diet, sleep, and exercise, but I now found that for walking she had used shoes 
with high French heels, and that she had blisters on her feet. Another analysis (Analysis 
34) of what was practically a " foremilk" showed the low percentage of fat and sugar which 
might be expected in a " foremilk." The percentage of proteids was very high, considering 
that it was a " fore-milk." 

ANALYSIS 34. 

Fat 0.65 

Sugar 5.25 

Proteids 3.82 

Ash 0.18 

Total solids 9.90 

"Water ; 90.10 

100.00 

The mother was now made to exercise in shoes fitted to her feet and having low broad 
heels, and to carry out rigorously all the rules which I had given her in the early part of 
her lactation. From this time the unfavorable symptoms in the infant disappeared, and it 
gained in weight and digested its food well. One week after this change was made in her 
shoes the analysis (Analysis 35) of her milk showed that it was now in normal equilibrium, 
and that the percentages of its elements were such as to lead me to conclude that the con- 
dition of the infant's digestion had become normal. 

ANALYSIS 35. 

Fat 3.34 

Sugar . 6.30 

Proteids 2.61 

Ash 0.16 

Total solids , 12.41 

Water 87.59 

100.00 



FEEDING. 205 

A few weeks later the infant again began to show symptoms of colic and general dis- 
turbance, and although the mother said that she had not been eating any food but what 
I had prescribed and that she was taking a long walk every day in properly fitted shoes, 
I knew by the high percentage of proteids which was shown by the analysis and by 
the condition of the infant that she was not telling the truth. I therefore decided that in 
the interests of the infant it would be better to wean it, which I did at once, and gave it a 
substitute food with a low percentage of proteids, on which it thereafter throve. 

Prolonged Lactation. — In what I am about to say regarding the 
extension of lactation beyond the normal period of twelve months I shall 
not include the more pronounced pathological conditions, especially of a 
nervous type, which occur in certain women under these circumstances. In 
healthy women the milk towards the end of a normal lactation has a 
tendency to return to the condition which we notice at the very beginning 
of lactation; that is, the product of the mammary gland becomes unstable 
and the percentages show a poor or a bad milk. In rare cases I have met 
with women whose milk remained of fair quality and who could continue 
their nursing into the second year without apparent detriment to themselves 
or to their infants. There is, however, no reason for thus continuing the 
lactation, even if the mother is healthy and the milk good, for at the end 
of the first year, human milk, whether good or bad, is not a food which is 
adapted to the corresponding stage of development of the infant's digestive 
organs. Unmodified cow's milk and starch in some form are much better 
adapted to the stage of development of the digestive organs of the second 
year, and should therefore at that time be substituted for human milk. 

Mixed Feeding. — It not infrequently happens to nursing women, when 
their general health is not in a normal condition, that the supply of milk, 
while good in quality, is not sufficient in quantity to satisfy the infant, and 
the question arises whether the mother's milk should be entirely given up, 
or whether it should be supplemented by other food. My experience is in 
favor of assisting the mother to nurse her infant during the earlier months 
of its life. I have found that where the substitute food is carefully regu- 
lated, this method is superior to that of withdrawing the mother's milk and 
feeding the infant exclusively upon a substitute food. 

We have, on the one hand, a better opportunity for regulating the 
mother's milk, by increasing or diminishing the number of the substitute 
feedings, and, on the other hand, if the mother's milk agrees with her 
infant, an excellent opportunity for making our substitute food correspond 
to what nature has provided. We can regulate more intelligently the 
infant's feeding by this method than by any other which is known. 

In arranging a mixed feeding we should in every case first liave an 
analysis made of the mother's milk, and, if her milk has been agreeing 
with the infant, make the substitute food correspond to the maternal. I 
would also recommend the practice of having an analysis of the mother's 
milk made at an early period of her lactation, as soon as the mammary gland 
has acquired its equilibrium and when the infant is thriving. This is a very 



206 . PEDIATRICS. 

important precaution, which may be of great use to us at a later period 
when the mother's milk may from many circumstances be disturbed or en- 
tirely lost. When such an accident happens, we know exactly Avhat the 
composition of the milk was on which the infant was thriving, and can at 
once arrange a proper substitute food. As an illustration of the truth of 
this statement, the following cases (Cases 84 and 85) are instructive : 

An infant (Case 84) was thriving on the milk of a healthy wet-nurse. One day, with- 
out giving any warning, the nurse left the house and never returned. The infant had to be 
put on a substitute food, as another nurse could not be procured. It was left in the middle 
of the hot weather without the food which had been so well adapted to its digestion. Un- 
fortunately, the precaution of having an analysis made of the wet-nurse's milk had not been 
taken, and it was some time before I was able to substitute a food which would agree with 
the infant. 

The second case (Case 85) was the one which I have already mentioned in Table 50, 
where the mother's milk, after careful management, had become fitted for her infant, and 
where the infant was thriving. One day the mother received a nervous shock from seeing 
the arm of another of her children dislocated. Within a few hours the milk entirely 
disappeared from her breasts and did not return. The analysis of her milk, which had 
been previously made, provided me with a guide by which I could at once have a substitute 
food prepared which would correspond to the food which the infant had been receiving from 
its mother. This was done, and the infant continued to thrive, showing no bad symptoms 
from the change of food. 

There are certain points to be considered in mixed feeding. First, if 
the mother's milk is agreeing with the infant, the substitute food should 
be of the same composition. Second, if the mother's milk is fully digested 
by the infant but is lacking in certain nutritive qualities, the absence of which 
prevents the infant's nutrition from being normal, we should, after the first 
week, alter the composition of the substitute food so as to make it fulfil 
the requirements of nutrition by increasing the percentage of that special 
element in the substitute which is deficient in the composition of the maternal 
milk. 

The times at which the substitute food should be given will depend upon 
the number of feedings which are found to be necessary in addition to the 
maternal feedings, and we should carry out the same principles in this mixed 
feeding that I have laid down for the general management of human breast- 
milk. If the mother's milk is lacking in quantity we should make the 
intervals between her nursings longer, and introduce one or two substitute 
feedings according as the age of the child requires shorter or longer intervals. 
If, on the contrary, the mother's milk is abundant, but either too strong or 
too weak, we should make the intervals of her nursings correspondingly long 
or short. In this way, with an accurate knowledge of the percentages which 
exist in the mother's milk, and with our power to change these percentages 
in substitute feeding, we can usually in a week or ten days regulate the sub- 
stitute feeding of the infant to such a degree that the mother's milk will also 
agree with the infant, and the infant will thrive again. 

Weaning. — There is no doubt that in a considerable number of cases 
occurring in the practice of physicians among civilized nations the mother's 



FEEDING. 207 

milk appears to be entirely unfit for her offspring, and it becomes a question 
whether the infant shall be withdrawn from its mother's breast temporarily 
or entirely. In such an emergency the careful and repeated analysis of the 
milk will enable us to determine this question wisely. 

I am convinced that a large niunber of infants are deprived of their 
natural food and weaned on msufi&cient grounds. We thus assist to keep up 
the resulting high mortality figures, and I believe that these figures will be 
sefisibly reduced when, in consequence of our taking a more enlightened 
view of the subject, we increase the number of infants who are fed dming 
the first three or four months of life upon a suitable breast^milk. 

A particular reason among many for waiting at least three or four months 
before weaning is presented by the fact that the stomach, after growing 
rapidly, has by the fourth or fifth month become a more perfect receptacle 
both as to size and to fiuiction. 

A number of nm^sing women find that at variable periods in the course 
of their lactation their milk begins to fail, and they are forced first to lessen 
the number of their nursings and then to wean entirely. The time, then, 
when the infant should be weaned almost always settles itself, without our 
intervention, at varying periods. The period of lactation, and the one T^hich 
might be called physiologically normal, can, when the breast-milk remains 
of good quality and quantity, be carried through the first year with benefit. 
We have certain guides which aid us in determining the proper time for be- 
ginning to wean. Physiologically, we know that certain functions, such as 
that which converts starch into glucose, are but slightly developed in the 
early months of life, and that they are only gradually established during the 
first year, and not, as a rule, perfected and in a condition in which we can 
call upon them with impunity until the last two or three months of that year. 
A sign which aids us in judging the progress of this development of the 
functions is the appearance of the teeth, calling our attention to the fact that 
nature is preparing the infant to digest and assimilate a form of food different 
from that which it has thus far received by sucking. The presence of six or 
eight incisors corresponds usually in the normally developed infant to the 
full development of the pancreatic secretion. 

A most valuable index which assures us that we need not be anxious to 
change the infant's food during the first year is the continuous increase in 
its weight, which, with a general healthy condition, results from a normal 
lactation. We must allow, however, for certain variations which in special 
cases are as important as is the rule to terminate the lactation at a definite 
period. The period of lactation may be curtailed or lengthened by a month 
or two according to the season of the year, the development of the teeth, or 
the condition of the child from illness or convalescence. Under such cir- 
cumstances it may be wiser to feed the infant from the breast during the 
heated portions of the year, and to wean it in cool weather, before or after 
the hot season, according to the individual case. An interdental pericxl is 
also preferable to a dental period, on account of the possible disturbances 



208 PEDIATRICS. 

which may arise in the latter and interfere with the proper actions of the 
new functions to which I have referred. In these exceptional circumstances, 
where there is any uncertainty as to the character of the milk which the 
infant is taking, a chemical analysis should be made at once, and repeated 
several times at intervals of a few days. These latter months, though not 
so difficult to manage intelligently as the early period of the infant's life, 
are much more likely to need careful supervision than the middle period, 
which, from its usually uninterrupted tranquillity, has been called the period 
of normal nutrition. 

Where on account of an insufficient supply of milk in the mother the 
infant has for some time become accustomed to several meals of a substitute 
food daily, the matter of weaning becomes a very simple one, for we know 
that we have a food which will agree with it ; but where we have to begin 
to wean directly and to adapt a food to the infant's digestive capabilities, as 
in cases of sudden failure of the milk or of sickness in the mother, this pro- 
cedure becomes much more intricate, and is at times fraught with consider- 
able danger. It is in these cases that an analysis of the milk made when 
the mother was in good condition often proves to be of great assistance. 

The method of weaning which I have adopted, and have found to be the 
safest and best, is the one which I have been enabled to use since having a 
milk-laboratory at my command. My rule is, provided that the infant is 
thriving or digesting its mother's milk well, to order from the laboratory a 
substitute food the percentages of the elements of which are very similar to 
what the infant has been taking from its mother. After a few days, if this 
food is agreeing with the infant, I begin to change the percentages of the 
different elements, with the object of gradually combining these percentages 
in such a way as to correspond to the percentages of the elements of un- 
modified cow's milk. This is easily and precisely accomplished. For in- 
stance, supposing that the infant is receiving from its mother a milk in which 
the percentage of the fat is 4, of the sugar 6.50, and of the proteids 2, I 
begin by giving the same percentage of fat (4), a lessened percentage of sugar 
(5.50), and an increased percentage of proteids (2.25). After a few days, if 
this milk is digested well by the infant, I make the fat 4, the sugar 4.50, 
and the proteids 3. In a few more days, if this food is digested well, I 
give plain cow's milk heated to 75° C. (167° F.), with lime water sufficient 
to make it slightly alkaline. If this still agrees with the infant, I soon 
change to cow's milk unheated and unmodified. 

Unless under very exceptional circumstances, sudden weaning is to be 
deprecated, though of course we must admit that it is sometimes done with 
impunity. The safest method, so long as we cannot judge beforehand which 
infants will be likely to be unfavorably affected by sudden weaning, is 
to take plenty of time and gradually ascertain by frequent changes, such 
as I have described, the food best adapted to the case. The infant should 
be gradually accustomed to this food, omitting the breast-feedings one by 
one, until finally we are sure that we have a substitute food on which it 



FEEDING. 209 

will thrive. At the tenth or eleventh month, provided that the ^yeaning of 
the infant is deemed desirable at so early a period, and after having accus- 
tomed it to taking plain cow's milk, starch in some form can also be given. 
It will be necessary to determine how much of this new element may be 
introduced into the infant's diet, carefully adapting the amount to its amylo- 
lytic function, which varies in different infants, and which has but lately 
arrived at its full development. When these changes have been accom- 
plished, the breast can with safety be entirely withdrawn. 

The danger of injudicious weaning was strongly impressed upon me in 
a case which I watched for several days through the courtesy of Dr. Sinclair, 
of Boston, and which it seems well to put on record. 

A delicate infant (Case 86), backward in its development, digesting well, and a little 
over one year old, was, without Dr. Sinclair's advice, suddenly deprived of the plentiful 
supply of breast-milk of its healthy mother and fed on oatmeal gruel. Vomiting and pros- 
tration immediately began, and continued until the oatmeal was omitted and the breast- 
feeding resumed, when the infant began to thrive again. Three weeks later the mother, 
through ignorance, suddenly and without any preparation fed it again on oatmeal gruel. 
On the following two days the infant vomited incessantly and was much prostrated. 
Several changes were then made in its food, but the symptoms grew worse, and the now 
thoroughly terrified mother again put the infant to her breast, with, however, this time a 
disastrous result, as her milk from nervous influences was so changed in its quality that it 
acted like a poison on the infant, who fell into a condition of collapse. Dr. Sinclair was 
sent for, and a few hours later I saw the case. A wet-nurse with a healthy infant four 
months old was immediately procured, and after several days of complete prostration the 
foster-infant began to revive, and later was gradually weaned without trouble. It may be 
well to add, for the encouragement of physicians who have cases of this kind to deal with, 
that after the mother's milk had poisoned the infant, and when I first saw it, the skin was 
gray and cold, the fontanelle sunken, and the eyes fixed, yet recovery took place. Under 
the same circumstances equal success in the treatment would probably be obtained by 
writing for a milk prescription to contain fat 2.50, sugar 5, proteids 1. This, of .course, 
would be an exceedingly weak food for an infant twelve months old, but it would be the 
safest combination to begin with, and could be increased in strength as the infant recovered. 

II. DIRECT SUBSTITUTE FEEDING.— Women.— Where for any 
reason it is impossible or inadvisable for the mother to nurse her infant, 
some other food must be substituted for the maternal. The milk of another 
woman approaches the mother's in its characteristics most closely, and 
should be obtained unless contra-indicated. 

It is generally supposed that the mother's milk, as a rule, is more likely 
to be suited to her infant's digestion than the milk of another woman ; but 
we have as yet too few cases where direct investigation by means of chem- 
ical analysis of the two kinds of milk has been made to lay down actually 
as a fact what we can merely grant as a supposition, that an idiosyncrasy 
in the mother's milk will find an analogue in her infant's digestive powei-s. 
The reverse of this proposition has also been held to be true, that at times 
some idiosyncrasy in the mother's milk will make it radically unfit for her 
infant. The probability, however, is that analyses Avill show cither that 
these varieties of milk are poor ones, or that the infants have unusually 
weak digestive powers. 

14 



210 PEDIATRICS. 

The fact that every mother cannot provide as good a milk for her infant 
as can be supplied by another woman finds its analogy in the inability of 
Jersey cows to rear their own calves. 

In connection with what I have said about an infant sometimes having 
an idiosyncrasy of digestion corresponding to some unusual percentage in 
its mother's milk, this case (Case 87) will be of considerable interest : 

The mother, a primipara, was healthy, but of a highly nervous temperament. The 
infant was thriving, but, as a measure of precaution in case of mammary disturbance at a 
later period of the lactation, I had an analysis (Analysis 36) made of the milk, with the 
following result : 

ANALYSIS 36. 

Fat 5.16 

Sugar 5.68 

Proteids 4.14 

Ash 0.17 

Total solids 16.15 

Water 84.85 

100.00 

The report made Jj^Dr. Harrington in connection with this analysis was, " The precipi- 
tated curd is quite similar in its appearance to that obtained in the analysis of cow's milk." 

I advised the mother on general principles to take more exercise, and ten days later 
another analysis (Analysis 37) of the milk was made. 

Ai^ALYSIS 37. 

Fat 4.88 

Sugar 6.20 

Proteids 3.71 

Ash 019 

Total solids 14.98 

Water 85.02 

100.00 

The second analysis was so similar to the previous one that, in conjunction with the 
perfect digestion and health of the infant, I concluded that this infant had an idiosyncrasy 
of digestion which enabled it to thrive on what would in most cases cause extreme disturb- 
ance. This view of the case proved to be correct, as the infant, which was under my care 
for a number of months, continued to thrive. If you will compare this analysis with that 
of the milk of the wet-nurse (Table 45, Analysis III., page 190) which I have previously 
described to you, where the high percentage of proteids caused vomiting of thick curds in 
the infant, you will be impressed with the striking similarity of the two milks. There is no 
doubt that in the majority of cases a milk such as is represented by these two analyses 
would be totally unfit, and would not only cause marked indigestion but often more serious 
results, such as convulsions. 

The following case (Case 88) presents an illustration of the reverse of 
the supposition that the mother's milk will suit her infant's digestion better 
than the milk of a wet-nurse : 

This infant (Case 89) was being nursed by its mother and showed continual disturbance 
of its digestion. At times it would be constipated, and again it would have attacks of colic 
with watery discharges. The colic was the most prominent symptom, and the child, though 
looking fairly well, was not gaining in weight. An analysis of the mother's milk showed 



FEEDING. 211 

that the percentage of fat was from 2 to 3, the sugar was of about the normal percentage, 
and the proteids varied from 3 to 3.50 per cent. The mother was of an extremely nervous 
temperament and was unwilling to carry out the rules for the management of her milk, 
which were absolutely necessary in order to reduce the high percentage of proteids, which 
evidently caused the disturbance. I therefore procured a wet-nurse, the analysis of whose 
milk was as follows : 

ANALYSIS 38. 

Fat , 2.96 

Sugar 5.78 

Proteids 1.91 

Ash , 0.12 

Total solids 10.77 

Water 89.23 

100.00 

The infant on taking this new milk ceased to have colic, but was more constipated and 
did not gain in weight. I therefore decided that it would be wise to increase the percentage 
of the fat in the nurse's milk. This was done by giving her considerably more meat to eat 
and making her take moderate exercise. The infant within a week began to gain in weight 
and to sleep well, the bowels ceased to be constipated and were moved naturally every day. 
There was also a plentiful supply of milk. Another analysis of the milk was then made, 
with the following result : 

ANALYSIS 39. 

Fat 3.31 

Sugar 6.45 

Proteids , 2.36 

Ash 0.16 

Total solids 12.28 

Water 87.72 

100 00 

This last analysis is of great significance. The increase in the percentage of the fat 
evidently regulated the fsecal movements. The total solids increased from 10.77 to 12.28, 
and the plentiful supply of milk made the infant gain, especially as it now was digesting 
perfectly. You will observe that it could digest a milk with a percentage of proteids below 
2.50, while it was a percentage of 3 in the mother's milk which prevented her from carrying 
on her lactation. 

In this case it will be seen that the milk of another woman was far preferable to that 
of the mother, and that the idiosyncrasy of a high percentage of proteids in the mother's 
milk did not find its counterpart in an idiosyncrasy in the proteid digestion of her infant. 

Wet-Nueses. — The general question as to whether a wet-nurse shall be 
employed is one which is of serious import, and must in each instance be 
decided by giving full weight to all of the many circumstances Avhich are 
involved in the case. Foster-feeding, where all the conditions are good, 
is superior to substitute feeding. The reverse of this statement, however, 
must always be kept in view, that a poor nurse, whether from temperament, 
or age, or general health, or the quality of her milk, had better be set aside 
where the conditions are favorable for a successful substitute feeding. It is 
perhaps better that the nurse's milk should correspond in age somewhat 
nearly to that of the infant she is to suckle, but a difference of some months 
in age may not be a contra-indication, as we are not yet in a position to say 



212 PEDIATKICS. 

definitely that the milk diifers sufficiently in different months to make this 
a reason of importance in choosing a nurse. A feeble child will nurse 
more easily and probably have better care from a multipara than from a 
primipara. The preferable age of the nurse is between twenty and thirty 
years. Her other requisites are a condition of good health and a quiet tem- 
perament. It will save much trouble and often obviate the frequent neces- 
sity for changing if before her engagement we have made a chemical analysis 
of her milk ; in fact, all the points which have been already referred to for a 
successful maternal nursing are of equal significance in the case of a wet- 
nurse. 

The general health of the wet-nurse should be carefully investigated, as 
women suffering from constitutional syphilis or any chronic disease are 
manifestly unfit for nursing. At the same time we should be careful, unless 
decided symptoms of disease are present, not to set aside the milk of a 
delicate-looking woman until it has been analyzed. The w^t-nurse (Case 
89) whose milk proved to suit the infant better than did its mother's w^as 
a frail, delicate-looking woman, but healthy. The mother, on the other 
hand, was a large, strong-looking woman, but of a very nervous tempera- 
ment. The rapid progress which is being made in the detection of the 
bacillus tuberculosis, not only in the sputum but also in the milk and in 
other secretions, may in the future be of much practical importance in the 
determination as to whether a woman should nurse an infant or not, but the 
present state of our knowledge is only sufficiently advanced for us to state 
that this bacillus has been found in the secretion of the mammary gland. 

Diet. — The same general principles that I have given in speaking of 
the diet of the mother should be applied to that of the wet-nurse. We 
should be extremely careful not to change suddenly the customary diet of 
a healthy nursing woman on purely theoretical grounds. For many years 
the mistake was made of keeping women on too low a diet in the early period 
of lactation, with the consequent delay of the establishment of a sufficiently 
nutritious milk-supply, and a corresponding initial loss of weight in their 
infants. Where, however, we are especially likely to err is in permitting 
a healthy, hard-working wet-nurse, accustomed to a somewhat coarse but 
nutritious diet, to adopt totally different habits of exercise and a diet to 
which she is "unaccustomed, rather than to have her continue her usual mode 
of life. This sudden change of habits frequently results in loss of health 
to the nurse, with its accompanying deterioration in the quality of her milk, 
or at least a change in its quality so as to make it an unfit food for her 
foster-child. A notable instance (Case 90) of too radical a change of habits 
was brought to my notice by Dr. Swift, of Boston. 

A wet-nurse had been procured for an infant (Case 90) ten days old. An analysis 
(Analysis I.) of her milk, two days before she began to nurse, is seen in the following 
table (Table 53). Her milk was digested well for two or three weeks, during which 
time she was fed on an abundance of good food and rich milk. The infant then began to 



FEEDIXG. 213 

vomit thick curds identical in appearance and toughness with the curds of cow's milk. 
Another analysis was made (Tahle 53, Analysis II.), which showed the amount of total solids 
to be increased in a most marked degree, the percentage of proteids corresponding far more 
nearly to that of cow's milk than to that of woman's milk. The nurse was then given 
plainer food and skimmed milk, and the infant ceased to vomit. The infant and nurse con- 
tinued well and strong during the whole year, the infant making a weekly gain in weight. 

I have here an analysis (Table 53, Analysis III.) of this same nurse's 
milk, made in the twelfth month of her lactation : 

TABLE 53. 
{Wet-Xurse.) 

Analysis I. Analysis n. Analysis m. 

Two davs before Rich food for a Food regulated and 

change of food. month. ^ agreemg with 

mfant. 

Fat 0.72 5.44 5.50 

Sugar 6.75 6.25 6.60 

Proteids 2.53 4.61 2.90 

Ash 0.22 0.20 0.14 

Total solids 10.22 16.50 15.14 

Water 89.78 83.50 84.86 

100.00 100.00 100.00 



AxiMALS. — I shall merely allude to the other method of direct substi- 
tute feeding by means of animals. In parts of France, notably in Brittany, 
infants are put directly to the coVs teats, and sometimes with good results. 
I know of one family of eight children all of whom were nursed by the 
family cow, and all of whom grew up healthy and strong. Yet the unde- 
sirabilit}' of feeding himian beings directly from the udders of animals is 
so manifest that this method need not be discussed. 

I shall at my next lecture deal with the third division of the First 
Nutritive Period, which I have designated '' Indirect Substitute Feeding.'^ 



214 PEDIATEICS. 



LECTURE VIII. 

THE FIRST NUTRITIVE PERIOD.— (Continued.) 
III. Indirect Substitute Feeding. 

To-day, gentlemen, I have asked you to meet me here at the farm 
connected with the Milk-Laboratory, in order that you should study practi- 
cally what will be of great use to you in your future careers. I would im- 
press upon your minds that in this subject of indirect substitute feeding we 
have many links of a long chain, all of which should be as nearly perfect 
as we can make them if we expect to obtain a satisfactory result. 

CHOICE OF POOD. — I have laid great stress upon the importance 
of feeding infants during the early months of life by means of human milk. 
We know, however, that in civilized communities the necessity will often 
arise for supplying the infant with food not from the human breast. In all 
probability the employment of substitute feeding will increase rather than 
decrease as our civilization advances. With this prospect before us, and 
appreciating the difficulties which in a large number of cases are liable to 
arise when we attempt to adapt a substitute food to the wants of an infant, 
it manifestly becomes a duty to endeavor to reduce the high mortality figures 
resulting from artificial feeding. With this purpose in view, we should care- 
fully investigate different methods of feeding and adopt some more uniform 
plan for starting human beings in life ; for diversity and not uniformity is 
now the rule. While inherited diseases contribute a certain proportion of the 
deaths which occur in infants, yet diversity of method in feeding is the most 
prolific source of disease in early infancy. The group of symptoms which 
for want of a better name is designated as difficult digestion occurs most 
frequently in the three periods when the infant's digestion is likely to be 
tampered with, — namely, in the early weeks of life, when experiments are 
being made to determine what food will be best to start with ; next, when, 
in addition to the irritation arising from the beginning of dentition, new 
articles of diet are added to the original food ; and, thirdly, at the time of 
weaning, when there is often a sudden and entire change in the character of 
the food. The proper management of the first of these periods is of the 
greatest importance, because it is the time when, as before stated, the stomach 
is in its most active period of growth, and w^hen the function of digestion is 
being established, and, following the rule of ftinctional establishment, is in 
a state of unstable equilibrium. 

We should recognize the fact that the problem of substitute feeding is 
not a simple one. We cannot reiterate too often that the question which 
commonly is supposed to be a simple one, and the one which in the great 



FEEDING. 215 

majority of cases is alone considered, — namely, " Which food shall we give 
to the infant?'' — is a misleading and insufficient one. The problem is a 
combination of factors of which the kind of food is only one, and I per- 
sonally have long been convinced that the neglect to investigate thoroughly 
and carry out in detail the combination of these by no means insignificant 
general factors has had much to do with our failures with substitute feeding 
in the past. It would seem, also, that the present is a most opportune time 
for raising a note of warning against allowing our enthusiasm over any one 
especial theory to warp our better judgment. There will surely be a reac- 
tion which will relegate to its proper place every theory built upon single 
factors of the problem before us, and which is actually doing harm by keep- 
ing in the background other theories which, each in its own sphere, as a 
significant part of a complete whole, may be of very great importance in 
the successful solution of the general problem. An error of oversight of 
one-eighth in a mathematical problem is not so great as one of one- fourth, 
but nevertheless the correcting of the greater error will not prevent an over- 
sight of the smaller from completely destroying a correct result. Until 
lately it has been the quality of the food which has been monopolizing to 
too great a degree the attention of the medical profession. To-day it is 
sterilization which in feeding has become prominent. Already one of the 
latest German writers on substitute feeding has stated that the physiology 
and pathology of infantile digestion depend not on the chemical but on the 
biological character of the food. If we are not on our guard, this exagger- 
ation of each single factor will prevail, and by its influence will blind us to 
much good work which in other directions has already been done, and which 
we cannot afford to ignore. Not that I would for a moment be understood 
to underrate the value of feeding an infant on a sterile food, for it has for 
years proved of very great benefit in my practice and that of others, but I 
predict that by just so much as we enhance the value of this one important 
part of the whole at the expense of others, just so much farther shall we 
be from an intelligent comprehension of the whole subject. 

To feed an infant one month old with six ounces of acid cow's milk every 
four hours, no matter how thoroughly such a mixtiu-e has been sterilized, 
would be a radical offence against well-known anatomical and physiological 
laws. It therefore seems to me that time will be well spent in the discussion 
of the subject of substitute feeding, if we investigate and endeavor to copy, 
each in its turn, the various devices which nature makes use of, for we must 
admit that we are not in a position to improve on nature's method. 

It is certainly wiser and more economical not to spare expense and 
trouble in arranging the infant's diet, for, as I liave explained, the period of 
active growth of an organ is the time when its function is readily weakened, 
and, when once weakened, the digestive function is a prolific source ot 
annoyance and expense in childhood and adolescence. Cheap foods and 
cheap methods of feeding, unless they are the best that can be procured, 
should not be tolerated in the early feeding of infants. "We often, however, 



216 PEDIATRICS. 

see a food recommended for a young infant because it is cheap and easily 
prepared, in spite of the fact that its well-known lack of nutritive ingre- 
dients would with adults stamp it as unfit for use. 

In discussing the treatment of disease we advocate what is best, without 
reference to what it costs, and then, in the special case where expense is an 
element which has to be taken into consideration, we endeavor to adapt our 
treatment to these considerations, and approach as nearly as possible to our 
first standard. In like manner I believe that we are doing wrong to the 
public if we allow ourselves to be handicapped in so difficult a question as 
infant feeding by the cry of expense. Infant feeding is an expense which 
is vital to the welfare of the human race, and we can, without being accused 
of extravagance, safely relegate to the province of the manufacturers of 
patent foods the recommending to the public of foods which if judged by 
the amount that is offered in bulk are cheap, but which when judged by 
their nutritive properties are extremely expensive. 

Our scientific knowledge and clinical investigations have not yet enabled 
us to follow nature exactly, and we therefore have not yet obtained an ideal 
method of substitute feeding. We must, nevertheless, go as far as the present 
state of our knowledge will allow, thus gaining a little ground every year ; 
and we must be especially careful not to be led astray by the fictitiously 
brilliant results which are reported from time to time in favor of certain 
foods. Instances are continually occurring where one food will fail and 
another, when substituted for it, will succeed, and yet these successes are 
merely temporary, and the mortality resulting from the use of various 
infant foods always remains far above that from the employment of human 
breast-milk. 

SOURCE OF POOD.— Having decided to substitute some food in 
place of woman's milk for the infant, we must decide from what source the 
elements of this food shall come. The food Avhich approaches most nearly 
in every respect the product of the human mamma is that produced by the 
mammse of other animals. The reason for this is that the food which all 
mammals provide for their offspring is an animal one, and consists of the 
same elements, although the mammary product of different animals varies 
in the percentage of these elements. 

Assuming, then, that average human breast-milk is the safest standard 
for us to copy, we are impressed with the fact that although a vegetable 
diet would often seem far the easiest method of procuring nourishment for 
young infants, yet nature has persisted in providing an animal one. We 
should therefore be very careful not to introduce into our substitute diet a 
vegetable element, which, as judged by our standard, must be a foreign 
element. Milk is the food which our reason tells us should be given to the 
young infant, and a milk which will approach as nearly as possible to the 
average human milk. That of various animals has from time to time been 
recommended as the best substitute for human milk, the recommendation 
being based on their analyses approaching more or less nearly the composi- 



FEEDING. 217 

tion of human milk. The milk, however, of all animals has to be modified 
to correspond to human milk ; and when we begin to modifH', it is as easv 
to change the proportions of the different constituents to a great degree as 
to a small. The fact that the milk of any particular animal approaches in 
its analysis nearly to that of the human breast is not of much significance, 
other considerations being far more important ; and it is most important of 
all that we should use one which can be obtained easily by the people at 
large. This at once settles the question that it is the milk of the cow to 
which we must turn our attention. Cow's milk may differ in its composi- 
tion from human milk to a greater degree than does the milk of the ass or 
the mare, whose milk approaches, so far as is shown by analyses, most nearly 
of that of all animals to hmnan milk ; but this in all probability is for the 
very reason that cow's milk is so universally used as a food for human 
beings of all ages. 

If the ass and the mare should be employed for dairy purposes to the 
same extent that the cow has been, there is every reason to suppose that their 
milk might change in its composition and their comparatively undeveloped 
mammary glands increase in size, just as has been the case with the cow, an 
animal which for thousands of years has been used for the production of 
milk, and which probably did not in the beginning give such an over-pro- 
duction of the mammary secretion as is the case now. In fact, on the monu- 
ments in Egypt, where formerly there was either no trade in milk or very 
little, we find represented cows with only slightly developed udders, while 
the generative organs of the male animals are clearly depicted, a fact of some 
significance when we remember the well-known tendency of the Egyptians 
to realistic representations. It is, then, from the public demand, and by 
breeding, that cows have been made to produce so much more milk than is 
necessary for the support of their young. Not only quantitative but quali- 
tative differences exist in animals according to the development of their 
mammary glands ; and, as Martiny has shown in his collection of statistics 
on this subject, the condition which determines the quantity and the quality 
of the milk depends on the development of the organ which produces it. 
The question of substitute feeding, then, is reduced practically to some 
modification of cow's milk, for this is the milk which is procured most easily 
every w^here, and, as the milk of all animals must be modified for the human 
infant, it is as easy to deal with cow's milk as with any other. 

A further exemplification that cow's milk is practically the imiversal 
source of the substitute food-supply for infants in most civilized communities 
is the fact that the various foods, patent or not, all depend for their basis on 
cow's milk, and that without this addition of milk they would show but an 
insignificant percentage of many of the most important ingredients ot' the 
food. Logically we should not speak of the various foods as such, but 
merely as adjuvants to cow's milk. If this is thoroughly undei*stood, much 
misapprehension regarding the apparently successful results of innumerable 
foods will be done away with. 



218 PEDIATRICS. 

One of the principal reasons for using cow's milk in preference to all 
others is that the cow has been kept under more strict control than any other 
animal has ever been. 

As I shall in a later lecture (Lecture X.^ page 278), when speaking of 
home modification, have to refer to the necessity of using milk from common 
cows on any farm, it will be well for you to know what the average analysis 
(Analysis 40) is of milk taken from large numbers of common cows all over 
the world. This average analysis represents the work of well-known 
chemists, such as K5nig, Forster, and others. 

ANALYSIS 40. 
Average Cow^s Milk. 

Eeaction Slightly acid. 

Specific gravity 1029-1033 

Water 86-87 

Total solids 14-13 

Fat 4.00 

Sugar 4.50 

Proteids 4.00 

Total ash 0.70 

Chlorine 13.45 

Sulphur 0.41 

Phosphoric acid 27.98 

Iron oxide and alumina , 0.44 • 

Lime 23.17 

Magnesia 2.63 

Potassium 53.00 

Sodium 4.49 

The differences between the constituents of the ash of human milk and 
of that of cow's milk are as follows : in cow's milk there are more lime, 
magnesia, potassium, much more phosphoric acid, and less chlorine and 
sulphur. 

THE CO"W. — Having chosen the cow for our primal milk-supply, we 
must consider whether any special breed is better adapted than others for 
accomplishing our purpose. To do this we should first examine chemically 
and microscopically the elements of the milk of those breeds which can be 
employed best throughout the civilized world. It has been found that the 
finer breeds of cows from the Channel Islands are more liable, when trans- 
ported from their home to countries where the climate is more severe, to 
contract diseases, such as tuberculosis, than are the animals represented by 
the Durham, Devon, Ayrshire, and Holstein breeds. The characteristic 
analysis of the milk of the finer breeds, such as Jersey and Guernsey, is 
represented in this table (Table 54) in comparison with that of the milk 
of other breeds ; the difference being mostly in the percentage of fat and 
slightly in the proteids. It may be well to state here that the percentage 
of proteids in the milk of pure Holsteins is also a little higher. 



FEEDING. 219 

TABLE 54. 

Cow^s Milk Analyses. 

T ^ Durham, Ayrshire, 

Jersey, Guernsey. _^ Vr 'i ^ • 

•^ Devon, Holstem. 

Fat 5.50 4.00 

Sugar 4.50 4.50 

Proteids 4.25 4.00 

Ash 0.65 0.65 

Total solids 14.90 13.15 

Water 85 10 86.85 

100.00 100.00 

It is for future research to determine whether there is a qualitative as 
well as a quantitative difference between the fat secreted in the milk of the 
Channel Island and that of the more common breeds, but at present it would 
seem wiser, in choosing our medium for modification, to select the milk of 
the hardy breeds of cows. 

A cow whose milk is to be used for purposes of infant feeding should be 
properly housed and w^ell cared for, as the domestic cow is an animal pecu- 
liarly sensitive to her surroundings, and her product is correspondingly 
liable to be thrown out of equilibrium. The milk product of a herd of 
healthy cows is much less liable to the variations so injurious to the infant's 
digestion than is the milk of any one cow. It is especially to be noticed 
how much easier it is by proper care to control exaggerated nervous 
influences upon the cow's product than upon the woman's. This at once 
suggests to us the question, where and how shall cows be taken care of? 

The ordinary cow is allowed to range over wide pastures which are 
sometimes over-flushed with herbage and sometimes parched by drought, 
and w^hich nearly always contain noxious weeds, which she seems eagerly 
to seek. Again, she is forced to drink from stagnant pools and polluted 
streams, and at other times suffers for want of water for many hours to- 
gether. She is also frequently exposed to storms. Cows cared for in this 
way are not those which provide the best milk for substitute feeding. 
These are the adverse conditions which surround the ordinary cow during 
the summer. . In the winter she is crowded in the stifling atmosphere of a 
close barn with the manure of the whole winter kept underneath the floor 
on which she stands. Her head is usually confined in a narrow stall. The 
fodder intended for the winter's supply is kept above her head, and is con- 
tinuously contaminated by the foul odors of the barn. She is turned out to 
the watering trough at periodical intervals. Thus she cannot be said to be 
cared for in a manner conducive to the equable function of her mammary 
gland. 

For cows to be used for the purpose of infant feeding a barn is needoii 
where each cow shall have at least fifteen Inmdred cubic feet of fresh air. 
The food should be kept where it cannot be contaminated. Tlie manure 
should be as carefully removed from the barn as if it were a human dwelling. 
The cow should have freedom for her head and limbs in wide stalls all the 



220 PEDIATRICS. 

year round. Large, dry, sunny exercise-yards should be provided for her. 
Her food should always be brought to her and selected with great care. Pure 
water should be provided, and suitable cups or troughs containing running 
water should be in her stall. The bedding should be fresh and free from 
mould or from any soil productive of bacterial growth. This can be accom- 
plished best by means of sand or dry soil constantly changed at least twice 
a day. Methods should be used to get rid of all the usual foul odors and 
free ammonia so commonly produced in barns. Cows should be carefully 
guarded against fright, the worrying of dogs, and unusual excitements of 
all kinds, which cause serious disturbance of the lacteal functions of domes- 
ticated cows, in contradistinction to those of cows in a more natural con- 
dition, as for instance the cows in a semi- wild state on the plains of Mon- 
tana, Texas, Australia, and the Pampas of South America. Excitement 
does not apparently injure the lactation of these cows, while it inevitably 
throws out of equilibrium the milk of the well-cared-for dairy cow. If the 
same care should be applied to regulating the woman's life as is employed 
here in this barn with these cows, we should encounter fewer difficulties 
in human breast-feeding. 

The feeding of the cows of this farm has for its object the production of 
an even, nutritious, digestible milk and the careful avoidance of over-stimu- 
lation of the lacteal secretion. For this purpose a somewhat wider ration 
than that employed for the production of milk to be used in butter-making, 
but somewhat narrower than that employed for the production of beef, has 
been found to be the best adapted. For example, a ration for the production 
of butter fat up to the limit of the cow's capacity would be in accordance 
with the ratio of Wolfe so often employed, — namely, one nitrogenous part 
to four and a half non-nitrogenous. The ration for the production of beef 
in its most economical manner would be that used by English feeders as 
prescribed by Lawes, — namely, a proportion of one nitrogenous to eight non- 
nitrogenous parts. The ratio which has been demonstrated to produce the 
best milk for infant feeding is the mean between these two, — namely, one 
nitrogenous part to five and a half or six non-nitrogenous parts. A constant 
use of this ratio in the combinations of many fodders and grains appears to 
have produced a reasonably large supply of milk with fair richness, but 
without over-stimulation such as would be shown by a disturbance of func- 
tion. Nitrogenous foods for cows are the leguminous groups of grasses and 
plants, such as the clovers, lucern, beans and peas, vetches, and other plants 
of like kind. Besides these fodders we have for nitrogenous foods suitable 
for producing milk for substitute infant feeding, such grains as wheat-bran, 
oil-meal in small quantities, and pea- and bean-meal. Of the non-nitro- 
genous fodders the principal ones are maize-stover, the hays from timothy, 
red top, orchard grass, Johnson grass, rye grasses, the bents, Kentucky blue 
grass, June grass, and oat straw. Most of the grasses in a green state 
afford a fairly balanced medium ration for substitute feeding. Of the non- 
nitrogenous grains the most suitable is maize-meal. We also have oat- 



FEEDING. 221 

meal and barley-meal, which contain less of tlie non-nitrogenous elements 
than the above, but still must be classed with them. The exact chemical 
analysis of any one ration used for feeding cows for our purpose must be 
carefully considered in accordance with the ratio of the digestible nutrients 
of the food, and this must of course be arranged practically from the recog- 
nized food tables. A great variety of food is necessary in feeding cows, but 
in the transition from green foods to dry, or the reverse, much care is needed 
to graduate the change, as disturbance in the equilibrium of the mammary 
gland is rapidly followed by injurious effects on the consumer. In past times, 
before I could rely as I do now on this carefully-managed change of rations, 
the spring of the year with its flush pasturage and the fresh grass following 
the autumn rains were fruitful sources of infantile digestive disturbance in 
my nursery practice. 

You will now appreciate how important are all these links in the chain 
which constitutes a successfid substitute feeding. The cows must be kept 
clean by grooming and the necessary washing, the precaution always being 
taken to rub the moistened parts dry. The milkers should be dressed in clean 
white suits and caps. Their hands and arms should be thoroughly scrubbed 
before milking. The hands in milking should be kept dry. The milk 
should be drawn with some force, simulating the action of the calf, and at 
each milking every drop of milk should be drawn out. The milk should 
be drawn into glass-lined pails and carried immediately from the barn to 
the milk-house, which should be a suflicient distance from the barn to be 
free from odors. No means yet known to science can prevent some few 
bacteria coming into the milk during the milking-time, though it is possible 
to reduce the number so greatly as to make the milk practically sterile for 
the purpose of infant feeding, particularly if the second half of the product 
of the udder alone is used and milked into sterile tubes. The first half 
probably contains many bacteria, which, entering from without, have reached 
the lower portion of the teat. 

Biology of the Milk. — The experiments on the biology of the milk 
of this special herd which I am showing you have been made by Professor 
Ernst and Dr. Jackson, and the results are shown in this table (Table 55). 
The specimens examined were taken from the mixed milk of the entire milk 
of the herd. 

TABLE 55. 

Bacteriological examination of milk from the entire herd 'tnilking shoioed six hoiws after 
the milking sixty-eight thoiisand colonies. 
Specimen. Heated to Minutes. Developed Bacteria. 

"Whole milk 75° C. (167° F.) 10 and 20 

Modified milk 75° C. (167° F.) 10 and 20 

Whole milk and modified milk . 65.55° C. (150° F.) 10 and 20 Numerous. 

In striking contrast with these results obtained by experimenting with 
the entire milking are some special experiments made on this same milk by 
Dr. Austin Peters and Dr. A. K. Stone, at Mr. Gordon's suggestion, for the 



222 PEDIATRICS. 

purpose of deciding whether it was possible to obtain a practically sterile 
milk at any part of the milking. The manner of performing the experi- 
ments was as follows : 

Dr. Peters was dressed in a freshly-boiled white suit and cap^ and had 
his hands and arms thoroughly washed Avith a 1 to 1000 bichloride of mer- 
cury solution. The cow^s udder^ teats, flanks, sides, groins, and abdomen 
were washed with the same solution, and dried with a freshly-boiled cloth. 
The milking was then done by Dr. Peters into bottles which had been care- 
fully sterilized at the bacteriological laboratory, with the following result. 

Of the four cows milked for this experiment and selected without special 
choice, the bottle marked 1 in each of the following sets of figures in this 
table (Table 56) represents the milk of the first half of the milking and 
drawn by the hand of the milker directly into the sterile bottles. Number 
2 in each set of figures represents milk drawn through a sterile canula directly 
into the bottle, while numbers 3 and 4, respectively, represent milk drawn 
by hand after more than one-half of the udder had been emptied. A bac- 
teriological examination of the milk in these bottles, by Dr. A. K. Stone, 
gave the following results : 

TABLE 56. 

Colonies. Colonies. Colonies. Colonies. 

1 141 167 19 53 

2 1 2 

3 6 

4 1 2 

The results of Dr. Stone's examination showed, first, that the milk ob- 
tained from the first half of the milking contained a comparatively large 
number of micrococci and fine bacilli of the same general appearance re- 
spectively ; second, that the milk drawn through the sterile canula was 
practically sterile, and that the milk drawn in the second half of the milk- 
ing by hand was so uniformly sterile as to awaken the suspicion that the 
isolated colonies might have been the result of the manipulation between the 
" cow and the plate.'^ 

These experiments at once provide us with a means of procuring a milk 
practically sterile but not sterilized. This experiment also seems to prove 
that the bacteria which are found in cow's milk do not necessarily come from 
external sources, whether they be of the cow herself or of her surroundings, 
but may also come from some part of the milk tract between the udder and 
the end of the teat. These conclusions, it may be said, are made with refer- 
ence to healthy cows. 

Infectious mainmitis, to some extent, seems clearly to be carried by the 
hands of the milkers from cow to cow. This also points to the fact that 
bacteria may find their way to the ducts through the teats. 

These experiments are of great practical importance when it is considered 
that while under certain circumstances it is impossible to obtain the advan- 
tages of such a farm as this and the modification of milk by means of 



FEEDING. 223 

laboratory processes, yet it may be of great necessity to the infant on account 
of sickness to be fed with a sterile fresh milk not sterilized. This could, 
of course, be accomplished on any farm with any cow by means of ordinary 
care in the milking, and by such rules as were carried out by Dr. Peters. 
The major part of the bacteria present in the milk are such as cause the 
usual acid fermentation which we recognize in the common souring of milk, 
but there are many species of bacteria which ought to be prevented from 
gaining access to the milk, arising from mouldy hay, straw, or fodder, par- 
tially decayed roots, and the natural decay of the wood- work of the barn and 
adjoining buildings. These latter varieties, w^hich are found to be especially 
inimical to the preparation of substitute foods, cause in some cases the alka- 
line fermentation and other abnormal conditions of milk. Every barn 
apparently has its own set of bacteria, and the flora in America do not 
exactly resemble the analogous European species which have so often been 
described. 

Eeaction of Cow's Milk. — It seems to be true that milk drawn from 
cows fed on the better grasses in a half-ripe condition is nearly or quite 
alkaline, while the milk from stall-fed cows, where dry fodder and grain 
only are used, is inclined to be acid. 

It will perhaps be interesting to you, inasmuch as grass feeding is not 
always practicable, to hear what has been done to produce a normal cow's 
milk which is alkaline and thus corresponds to normal human milk. 

The importance of the subject lies in the well-recognized fact that the 
infant's digestive functions have been from time immemorial better adapted 
to the digestion of an alkaline or a neutral fluid than of an acid one. 
Whether the moderately alkaline reaction of human milk is an important 
factor in the problem of infant feeding is a question which future investiga- 
tion alone can completely prove, but with our present knowledge we are 
not prepared to dispense with even the least important of the many factors 
which make up this problem. At any rate, we should be very suspicious of 
a breast-milk which shows an acid reaction. In the preparation of an in- 
fant's food from cow's milk, according to the latest experiments by means of 
modification, the best results have been obtained by making the reaction of 
this food correspond to that of normal human milk. This, up to the pres- 
ent time, has been done best by the addition of an alkali, which is the only 
foreign element that it has been found necessary to employ. 

My attention was first drawn to the possibility of obtaining an alkaline 
cow's milk corresponding in its reaction to that of human milk by INIr. G. 
E. Gordon, who, by his extended and intelligent investigation of this subject 
carried on for so many years, has given such a stimulus to these questions 
of clinical interest. Many years ago it was noticed that cows fed on certain 
pastures, such as occurred in Kentucky, represented by the Kentucky blue 
grass, and also in many other parts of the West, produced at the height of 
the season of such grass a product which was alkaline rather than acid, and 
which remained alkaline for a number of hours after milking. It is also of 



224 PEDIATRICS. 

course well known that milk in general, wherever it is produced throughout 
the world, has an acid, or at least an amphoteric, reaction. This informa- 
tion at once incited the investigation of the food values which existed in 
these peculiar pastures. A careful analysis showed that the nitrogenous 
elements of this grass bore a certain proportion to its non-nitrogenous 
ones, — namely, about 1 to 4.5. We should naturally suppose that if we 
combined nitrogenous and non-nitrogenous foods in the proportion of 1 to 
4.5 the product of cows fed upon this combination would resemble closely 
the product of cows fed upon the pasture grasses already mentioned. This 
to some extent has proved to be true, but not so completely as is to be de- 
sired for the precision needed in infant feeding. It is therefore interesting 
to record that the experiment of supplying the non-nitrogenous proportion 
of the food with sugar-beets (ten pounds to each cow daily) of the highest 
saccharinity has accomplished unlooked-for results. The cows which were 
experimented with in obtaining these results were under observation for 
three months, and were cared for in the same barn and under the same 
general conditions. Two-thirds of this herd were fed on hay and grain 
combined in the ratio of 1 nitrogenous to 4.7 non-nitrogenous parts. The 
remaining third of the herd was also fed according to the same ratio, 
but this ration, so far as the non-nitrogenous elements were concerned, 
was made up partly of Austrian sugar-beets grown for this purpose. No 
beets were given to the first two-thirds of the herd just spoken of. During 
the three months when the experiments were being made, the reaction shown 
by the milk to common litmus paper was constantly as follows : the milk 
of the cows fed partially on the beets exhibited a neutral or feebly alkaline 
reaction, while that of the cows that received no beets showed a somewhat 
acid reaction. 

A still more delicate test of the reaction of the milk of the entire herd 
was made by Dr. Austin Peters, of Boston. Hay and grain without beets, 
as previously stated, had been the food of two-thirds of the herd, and ten 
pounds of beets to each cow daily had been fed to the remaining third. 

The results of the testing of the alkalinity of this milk at the various 
stages of the experiment were as follows. The milk of the cows which had 
been fed with beets, when tested directly by Dr. Austin Peters as it was 
milked into the pails and where it had a temperature of 33.88° C. (93° F.), 
invariably gave the following reactions : 

Blue litmus paper gave no change whatever. 
Ked litmus paper was turned slightly blue. 
Cochineal and ammonia paper turned still bluer. 

The mixed milk of the whole herd in the vat and at a temperature of 
5.55° C. (42° F.) was then tested by Dr. Peters, with the following results : 

Blue litmus paper showed no change. 
Red litmus paper was turned slightly blue. 
Cochineal and ammonia paper was turned still bluer. 



FEEDING. 225 

Finally the mixed milk of the whole herd, after being carried twelve 
miles to the Laboratory, was tested by j\Ir. Gordon with cochineal and 
ammonia paper ; the paper was fonnd to turn just as blue as when the milk 
was tested in the vat at the farm. 

These experiments are of great interest as showing that not only can the 
product of the cow, so far as its reaction is concerned, be made to correspond 
to that of human beings by means of perfectly natural feeding and under 
perfectly normal conditions, but that this alkaline modification can be 
produced to such a degree that one-third of the milk is sufficient to destroy 
by its alkalinity the acidity of the remaining two-thirds. 

THE MILK-HOUSE. — After the cows are milked, the milk is carried 
quickly from the cow to the milk-house, which in this instance is over a 
hundred yards from the barn and is completely isolated from all other 
buildings. To prevent the milkers from going into the milk-room, the 
milk is poured by means of a block-tin pipe through the wall of the milk- 
room into a large ice-lined block-tin tank, which is also the mixer for 
the milk of the entire herd. In the space of four minutes, by means of an 
ice-jacket, the milk is cooled from 33.88° C. (93° F.) to below 4.44° C. 
(40° F.). This is to rapidly remove the heat, which is conducive to bac- 
terial growth. The milk passes through eight thicknesses of sterilized gauze 
on its way to the tank. 

The milk-room is practically clean from a bacteriological stand-point, 
for the walls and floor are kept wet with clean water, and all dust is ex- 
cluded. The milk is drawn into these jars (Fig. 50, page 246), in which 
it is to be transported. The jars are then sealed, packed in ice, and in a 
few hours delivered at the place where the milk is to be used for substitute 
feeding. 

After this treatment of the milk I have had repeated bacteriological 
examinations made on its arrival at the Laboratory, with the uniform result 
that it has proved to be comparatively sterile, and at times it has contained 
either no colonies of bacteria or only one or two. 

Xo antiseptic can, without danger to the infant, be used about the 
cow, while all the mechanical devices heretofore tried to take the place of 
manual milking have inevitably tended to impair the lacteal function of 
the udder. 

CHARACTERISTICS OP COWS WHICH PRODUCE MILK 
SUITABLE FOR INFANT FEEDING.— Some of the marks which dis- 
tinguish the breeds best adapted for infant feeding are : 
I. Constitutional vigor. 
II. Adaptability to acclimatization. 

III. Notable ability to raise their young. 

IV. Freedom from intense inbreeding. 

V. A distinctly emulsified fat in the milk. 
VI. A preponderance in the fats of the fixed over the volatile gly- 
cerides. 

15 



226 PEDIATRICS. 

You must understand that the volatile glycerides do not exist in the 
mammae, but are formed in the milk soon after the milking, and that in 
some breeds this occurs more quickly than in others, such as those from the 
Channel Islands. 

By means of these distinguishing marks we can eliminate from the cows 
which we wish to use for infant feeding such breeds as the Jersey, Guernsey, 
and any others in which intense inbreeding has been carried on and in which 
acclimatization has not been perfected, leaving for our purposes such breeds as 
Mr. Gordon has here to show you, — namely, the Durham, Devon, Holstein- 
Friesian, Ayrshire, Bretonne, and Brown Swiss. These you will under- 
stand are types of the breed, though not in all instances pure bred. These 
breeds, of course, do not represent all of those available for substitute feed- 
ing, for we may mention many others equally good each in its country. 
For example, the Kerry of Ireland, the Eed Polled of England, the Dutch 
Belted and the Flemish, also the Flamande and the Cotentine of France, 
the Norman breed of Normandy, and, besides the Brown Swiss just spoken 
of, and which you will presently see, the Simmenthal, sometimes called 
Bernese, of Switzerland, also the Chianina of Italy, and the Allgauer of 
Germany. I say very little about the native cow of this country, the " Red 
Cow," because through many generations of neglect and exposure in winter 
she has undoubtedly acquired an impaired digestion and does not respond 
readily to appropriate changes of food. 

Mr. Gordon will now show you the types of those breeds which represent 
best in his herd the requirements of substitute feeding. 

The first cow (Fig. 43) represents the best type of the milking Durham or Shorthorn. 
She has great constitutional vigor, great capacity for food, a perfect digestion, is of a placid 
temperament, not easily frightened, and yields a large quantity of rich milk, the analysis 
of which is as follows : 

ANALYSIS 41. 

Fat 4.04 

Sugar 4.34 

Proteids 4.17 

Ash 0.73 

Total solids 13.28 

Water 86.72 

100.00 

The physical characteristics of the Durham are variety in color, a white nose (this 
especial Durham is a strawberry roan and white), large size, rather small head, large udder, 
and a placid, intelligent, and rather refined appearance. 

The next cow (Fig. 44), the Devon, has the same general characteristics as the Durham, 
combined with great gentleness and docility. The color is, as you see, almost uniformly 
red, with the nose generally white. They are of medium size and have medium-sized 
udders. They are very gentle and very vigorous. They come from an old south-of-Eng- 
land established breed, and have been known for centuries. They have never been intensely 
inbred or pampered. They have a fair capacity for food, are not easily frightened, and their 
digestion is good. They give a moderate quantity of milk of medium quality, the analysis 
of which is as follows : 




Fig. 43.— Durham. (Shorthorn.) 




Fig. 44.— Devon. 




I'lu. 15.— Avrshire. 




Fig. 46.— Holstein-Friesian. 




Fig. 47.— Brown Swiss grade. 




Fig. 48.— Bretonne. (Naturally straight back, arched from cold.) 



FEEDING. 227 

ANALYSIS 42. 

Fat 4.09 

Sugar 4.32 

Proteids 4.04 

Ash 0.76 

Total solids 13.21 

Water 86.79 

100 00 

The next cow (Fig. 45) is an Ayrshire, descended from a celebrated race in the south 
of Scotland dating back many centuries. Their constitutional vigor is great. They have 
great capacity for food, a good digestion, a temperament rather nervous, arising, probably, 
from an out-cross with the wild cattle of Chillingham. They are not so hardy as the 
Durham, but are very free from disease. The prevailing color is brownish red with white 
spots or flecks, though many of the best Ayrshires incline to a pure white or to a dark brown 
without white. This one is brown and white and is of medium size. Their horns turn 
upward and backward. They have large udders, and yield a large supply of milk, with 
the following analysis : 

ANALYSIS 43. 

Fat 3.89 

Sugar 4.41 

Proteids 4.01 

Ash 0.73 

Total solids. ." . . 13.04 

Water 86.96 

100.00 

The next cow (Fig. 46), which is of " the thorough dairy type, is called the Holstein- 
Friesian. This cow represents the most perfect milking animal known, having every charac- 
teristic of a cow suitable for our purpose, but her milk is so light in its total solids that it is not 
so profitable as the other breeds. These cows are usually black and white in color, with black 
noses. The fat-globules of their milk are very small and evenly distributed, and the emul- 
sion is perfect. These cows are usually large, weighing about 54.5 kilogrammes (about 1200 
pounds). This special cow is now two years old and is not full grown. They are very 
domestic and gentle. They have large udders, and yield a larger quantity of milk than any 
other known breed, although the analysis shows it to be poorer in quality : 

ANALYSIS 44. 

Fat 2.88 

Sugar 4.33 

Proteids 3.99 

Ash 0.74 

Total solids 11.94 

Water 88.06 

100.00 

The fifth cow (Fig. 47) is a Brown Swiss grade. The Swiss element is derived from 
the hardy race of the Alpine pastures. They are very vigorous, stand cold well, are docile 
and not easily frightened. They are rather under medium size, and are generally brown in 
color. The nose is black, with a mealy ring around it. They have a slightly dished face, 
and the udder is of medium size. They are very healthy, and yield a fair supply of milk of 
about the richness of the Devon, the analysis of which is as follows : 



228 PEDIATRICS. 

ANALYSIS 45. 

Fat 4.00 

Sugar 4.30 

Proteids 4 00 

Ash 0.76 

Total solids 13.06 

Water 86.94 

100.00 

Finally, here is a little Bretonne cow (Fig. 48), known all over Europe as the " cow for 
the family." Cows of this breed have all the characteristics of the good domestic cow 
which I have already mentioned. They are blue-black or black and white in color, and 
have black noses, which are sometimes mottled and are rarely white. A distinguishing 
mark is that the mucous membrane of the mouth is always white, while that of some other 
breeds is black or gray and white. They are small, but have large udders, which produce a 
medium amount of milk, large, however, in proportion to their size. This special cow is cold 
from standing, and this is the reason that her back is arched. 

I have mentioned the natural constitutional vigor of these cows, because 
certain breeds of cows in some localities do not appear to be able to resist 
the attacks of common diseases, such as tuberculosis. A notable illustration 
of this is represented by the Jerseys in America. 

It is very important that certain precautions should be taken to pre- 
vent the use of cows which are affected with tuberculosis. It is probable 
that three per cent, of the cows whose milk is used for food are tuber- 
culous. Where tuberculosis is developed to such a degree in the cow as 
to be dangerous to the consumer of the milk, the disease can usually be 
detected by a skilful veterinarian by means of the physical examination 
which is employed in cows. But, as it is a disputed question at present as 
to when the milk of a tuberculous cow becomes affected, it is wiser to adopt 
all measures of precaution known to science. Of these measures the one 
which is most efficacious in detecting even the incipient stages of tubercu- 
losis is that which is used here on this farm. 

The cows employed for the production of the primal milk-supply for 
the Milk-Laboratory have been subjected to the test for the diagnosis of 
tuberculosis. This test is known as the "tuberculin test.^' The method 
of making this test is as follows : 

At about 9 o'clock p.m. the temperature of the cows is taken per 
rectum with an ordinary clinical thermometer. The temperature in healthy 
cows may vary from 37.7° C. to 39.7° C. (100° to 103i° F.), according to 
age, the weather, the condition of. pregnancy, or the period of the day. As 
soon as the temperature of the individual cows is recorded, each one receives 
a subcutaneous injection of from 2 to 3 c.c. of a ten per cent, solution (1 c.c. 
of Koch's tuberculin to 9 c.c. of a one-half per cent, solution of carbolic 
acid in sterilized water), the proportion being adapted to the weight and 
vigor of the especial cow. This fluid, for convenience and uniformity, is 
introduced in the upper part of the right shoulder. After an interval of 



FEEDING. 229 

eight hours — that is, at 5 a.m. — the temperature is again taken per rectum, 
and this procedure is repeated at intervals of three hours until 2 p.m. 

At 5 A.M. the temperature should in healthy cows be slightly lower than 
that found on the previous evening. Subsequently the temperature should 
not rise above that of the first record at 9 p.m. No rise in temperature 
occurs in a cow which is free from any tubercular affection. Where the 
temperature rises to 41.1° to 42.2° C. (106° to 108° F.), it indicates disease 
and marks the cow as tuberculous, though even a lower reading sometimes 
marks the presence of the disease in cows whose normal temperature was 
low. 

No water should be given to the cow during the period of the experi- 
ment, because it is found that the temperature, as soon as the water reaches 
the stomach, is lowered to or nearly to normal, according to the amount and 
temperature of the water. 

This test is a very delicate one, and records the presence or absence of 
the slightest tuberculous infection, even if the disease has not previously 
affected the cow in any way which can be detected by an ordinary physical 
examination. 

At the point of inoculation there are marked tenderness and heat in cows 
that are tuberculous for many hours after the conclusion of the test, while 
in cows that are healthy the skin is not irritated by the use of the syringe. 

I have now explained to you what I consider to be a very important part 
in accomplishing a successful substitute feeding. I shall at my next lecture 
describe the characteristics of the milk which is brought from the herd to 
the Laboratory, where it is modified. 



230 PEDIATRICS. 



le:cturk IX. 

III. INDIRECT SUBSTITUTE FEEDING.— (Continued.) 

General Kemarks on Substitute Feeding — Comparison of Woman's and Cow's 

Milk— Milk-Laboratories. 

In my last lecture I explained to you at the farm the methods employed 
for obtaining a primal milk-supply especially adapted to infant feeding, and 
the types of cows which experience has proved to be the best for this pur- 
pose. You will now understand that where human milk that is suited to 
the individual infant cannot be obtained, or if obtained cannot be regulated 
by modification, it is desirable to substitute for it the combination of elements 
which such a human milk represents. To accomplish this we must have 
materials which, while closely resembling the elements of normal human 
milk, are easily obtained. 

Physiological experiments on the mammary gland show that the albumin 
of the milk is not directly an exudation from the lymph-vessels supplying 
the mammary gland, but that it is actually modified in the gland itself. We 
thus see that the mammary gland, besides being an elaborator for infant nu- 
trition, is also a modifier. This suggests to us that the modification of milk 
is not contrary to nature's method of preparing food for infants. Following, 
therefore, nature closely, we have learned that the proper modification of 
absolutely pure and fresh milk is the vital principle which should underlie 
our efforts to perfect a substitute food. I have already shown you the best 
method of obtaining a stable and perfectly pure cow's milk. When this 
milk is obtained, how shall it best be modified ? 

In addition to the general principles which I have enunciated concerning 
maternal feeding, and which apply equally to substitute feeding, there are 
certain principles connected especially with substitute feeding to which I 
desire to call your attention before taking you to the Milk-Laboratory, in 
order that you may use the Laboratory to the best advantage. 

The infant at the breast receives for its nutriment a fluid which is fresh, 
sterile, neutral, or faintly alkaline, which has a temperature of 36.7°-37.8° 
C. (98°-100° F.), furnished in an amount proportionate to the age and size 
of the consumer. It is this fluid which we have to copy in every possible 
detail when we undertake to prepare a substitute food. We should also 
consider as foreign matter, to be carefully avoided, any element which we 
know is not to be found in the milk we are copying. Thus, and thus only, 
can we arrive at the proper solution of this intricate question of substitute 
feeding. 

The analyses of human milk, which I have shown you in a previous 



FEEDING. 231 

lecture (Lecture VII., page 179), teach us that there is a great capacity in dif- 
ferent infants to assimilate a variety of proportions of the same nutritive 
elements. In all probability the infant needs a variety in its food to some- 
what the same extent as does the adult. In order, therefore, to copy nature 
closely, we must have some means of preparing a food not only for the many 
but for the individual, and when introducing new methods for preparing 
a substitute food we must recognize the necessity for providing for many 
prescription possibilities. In this busy age of scientific rational medicine 
physicians all over the world demand, first, means of saving time, and 
second, exact methods of work, which in themselves soon become time- 
savers. In every branch of our art the tendency is growing year by year 
to systematize the detailed and laborious work of the individual for the 
common practical use of the profession at large. I have long felt that in 
some way the subject of substitute feeding should be reduced to a more exact 
system, and that an effort should be made to rescue this important branch 
of pediatrics from the pretensions of the owners of proprietary foods and 
the hands of ignorant nurses. With this end in view, I have given my 
professional assistance to the establishment of a system of milk-laboratories 
where the materials used shall be clean, sterile, and exact in their percent- 
ages. These laboratories have been placed under the control of educated, 
intelligent men in whom we have the same confidence that we have conceded 
to the pharmacist, and we can write directions for infants' foods and send 
them to these laboratories just as, in the treatment of disease, we write our 
prescriptions for the division of one drug or the combination of several. 
As the pharmacist has nothing to do with the various methods of treating 
disease, so the milk-modifier is simply required to carry out the directions 
and ideas of the physician. No special school of medicine need be repre- 
sented. No special method of feeding need be undertaken. An opportunity 
has, however, for the first time in the history of medicine, been presented 
for the physician to carry out his own methods, and these methods for the 
first time to be judged on a fair basis. In this way only can each clinical 
observer, when lacking in success, be sure that it is the fault of the food he 
is giving, and not because the food has varied from what he supposed he 
had ordered. 

I have come to the conclusion that even slight changes in the percentages 
of the three important elements of milk of which we have most accurate 
knowledge — namely, the fat, the sugar, and the proteids — are of real value 
in the management of the digestion and nutrition of the infant, and that 
these changes are often necessary day by day as well as month by month. 
With this fact impressed upon us, we can well see that no one mixture will 
in all cases prove successful, but that a great variety in the percentages of 
the different elements of the milk will be needed in substitute feeding just 
as they already exist in maternal feeding. This explains the diversity of 
results obtained in the past with the same food by different practitioners. 

The means for prescribing a diversity in the elements of milk, according 



232 PEDIATEICS. 

to the idios}Ticrasy of the digestion we are dealing with, is supplied bv a 
milk-laboratory equipped with special machinery and controlled by educated 
milk-modifiers. From what I have previously said, you will understand 
that purity of the original material is the first object to be attained. This 
milk should be obtained from coavs bred, fed, and cared for in the manner 
which was described in the last lectm^e, and, in order to insure absolute 
uniformity in the methods which I then explained to you, untiring vigilance 
must be used in the super^^ision of the farm, cows, and milk-house, and in 
the transportation of the milk from the farm to the laboratory. It is also 
necessary that the cows should be under the medical supervision of a skilled 
veterinary surgeon. These are all questions which to my mind have been 
definitely decided, but which now need time and attention devoted to them 
to insure their being systematically carried out. As in all other advances 
which are made in practical medicine, so also in this one it is well to adopt 
at once a high standard of work and to demand everything that can in any 
way tend to perfection. We may not always be successful in carrying out 
all the details, but until we are so perfection will not be arrived at. Bear 
in mind, then, the chain of facts which I have endeavored to simplify and 
explain to you, and understand that each link of that chain is of vital im- 
portance, because, if broken, the value of the whole chain may be lost. 
One end of this chain is at the milk-farm. We have followed it from 
the stall to the milk-house, and from the milk-house to the laboratory, and 
we must now so manage the continuation of this chain that it shall come 
unbroken and intact to the infant consumer. 

Apparatus for Feeding. — Human ingenuity has not yet been able 
to devise anything which approaches the perfection of nature's apparatus for 
feeding, and the best that we can do to offset this complex mechanism is to 
adopt that which is exactly the reverse, — namely, an apparatus of absolute 
simplicity, — and thus combat the tendency to fermentation by preventing, 
through perfect cleanliness, the apparatus from becoming a source of fermen- 
tation. To accomplish this object the receptacle from which the infant is to 
be fed should be made of glass, in the form which will enable it to be most 
easily cleansed, and, as in the future the question of transportation will un- 
doubtedly be a grave one, the receptacle should be such that it can be adapted 
to transit and not easily broken. For this purpose, what are practically 
test-tubes fulfil these indications best. These tubes have open mouths larger 
than those usually provided in the ordinary nursing-bottle, and, having no 
angles, are readily cleansed. The artificial receptacle is not self-regulating, 
and hence we must determine the amount of food in bulk which nature pro- 
vides for the average infant at different ages, and from these average figures 
deduce the proper amount for the especial infant. The feeding-tubes are 
graduated for the more important periods of growth, for the purpose of 
continually impressing upon the mother and nurse what the physician often 
has the opportunity of telling them only at the beginning of the nursing 
period, — namely, that the error is in giving too much food rather than too 



FEEDING. 



233 



little, an error, also, which naturally results when, as is commonly the case, 
the usual eight-ounce nursing-bottle is provided as the receptacle at the very 
beginning of infantile life. 

I have found that I can easily convince most mothers of the mistaken 
zeal of nurses who advocate giving the yoimg infant large amounts of food, 
by showing them the size of the infant's stomach at birth and comparing this 
small tube which corresponds to the stomach's capacity with an eight-ounce 

nursing-bottle. 

Fig. 49. 




Stomach from infant five days old ; capacity 25 c.c. 
(Natural size.) 



Glass cylinder, capacity 25 c.c 
(Natural size.) 

I shall presently show you these tubes at the Laboratory, and I speak 
of them here merely to impress upon you the great importance of carefully 
attending to the smallest details in substitute feeding. 

Nipples. — A nipple made of fine soft rubber adapted to the especial 
infant as to its size and the holes for the milk is substituted for the maternal 
nipple. These rubber nipples should be large enough to be turned inside 
out and carefully cleansed after each feeding. They should be boiled after 
being used, and kept in cold water with a little soda in it. They should be 
renewed frequently, the oftener the better : preferably a new one should 
replace the old one three times a week. It will be found that the rubber 
nipple has to be adapted to the taste of the especial infant, and that it often 
has to be changed as to its size, texture, and holes before the infant is satisfied 
with it and sucks satisfactorily from it. 

Intervals of Feeding. — I have already shown you in this table 
(Table 42, page 182) the intervals of feeding which should be, as a rule, 
adhered to in maternal nm-siug. These intervals should also be adopted in 
substitute feeding, but the amount of food to be given now becomes a promi- 
nent feature in the division of the total amount of food which it is proper to 



234 



PEDIATRICS. 



give in the twenty-four hours, according to the age and development of the 
individual infant. 

Amount at each Feeding. — The infant's weight and its gastric ca- 
pacity quite frequently do not correspond. Yet there seems to be no doubt 
that the weight is a condition to which marked consideration should be given 
when we are attempting to determine so difficult a question as the proper 
amount of food to be given at each meal in the early months of life. The 
amount to be given at each feeding must be carefully regulated according 
to the gastric capacity, and I have stated in a previous lecture (Lecture IV., 
page 80) what the gastric capacity is at different ages. 

I have arranged some tables (Tables 57 and 58) to show how the inter- 
vals of feeding and the amount of food to be given should correspond to 
the gastric capacity at different periods of the first year. I think that they 
wdll prove useful to you w^hen you have to decide on the amount of food 
which it will be safe and wise to begin with in your cases. It is so im- 
portant to avoid stretching so easily distensible an organ as the stomach that 
it is wiser to give too little rather than too much food in the early days of 

life. 

TABLE 57. 

General Rules for Feeding during the First Year. 

The day feedings are supposed to begin with the Q A.M. feeding and to end with the 10 P.M. 

feeding. 



Age. 


Intervals, 
hours. 


Number of 

Feedings in 

24 hours. 


Number of 

Night 
Feedings. 


Amount at each 
Feeding. 


Total Amount In 24 

hours. 










Cubic 




Cubic 












Centimetres. 


Ounces. 


Centimetres. 


Ounces. 


1 week . . 


2 


10 




30 


1 


300 


10 


2 weeks . 


2 


10 




4.5 


1^ 


450 


15 


4 weeks . 


2 


9 




75 


^ 


675 


22^ 


6 weeks . 


^ 


8 


-l 


90 


3 


720 


24" 


8 weeks . 


^ 


8 




100 


H 


840 


28 


3 months . 


2J 


7 





120 


4 


840 


28 


4 months . 


2k 


7 





135 


4^ 


945 


31^ 


5 months . 


3" 


6 





165 


^i 


990 


33 


6 months . 


3 


6 





175 


5f 


1035 


34^ 


7 months . 


3 


6 





190 


H 


1125 


37J 


8 months . 


3 


6 





210 


7 


1260 


42 


9 months . 


3 


6 





210 


7 


1260 


42 


10 months . 


3 


5 





255 


^ 


1275 


42^ 


11 months . 


3 


5 





265 


8| 


1312 


43} 


12 months . 


3 


5 





270 


9 


1350 


45 



The first month being the most critical period for the infant's nutrition, 
as it is the time when the equilibrium of its metabolism is being established 
and its chance for life is least, especial interest should be attached to the 
series of careful investigations made at the Children's Hospital in St. Peters- 
burg by Ssnitkin to determine the amount of food which should be given in 
the first thirty days of life. As the result of these investigations he deduces 
the rule, " the greater the weight the greater the gastric capacity." Ssnitkin's 
general results (Table 58) show that one one-kundredth of the initial iceight 



FEEDING. 



235 



should he taken as the figure icith which to begin the computation^ and to this 
should be added one gramme for each day of life. 

TABLE 58. 
Illustration of Ssnitkin's Rule to aid in adjusting the Food to especially difficult Cases in the 

first Thirty Days. 

Amount at each Feeding. 
Initial Weight. Early Days. At 15 Days. 

3000 grammes ... 30 grammes. 30 -f- 1-5 = 45 grammes. 

(About 1 ounce.) (About IJ ounces.) 
4500 grammes ... 45 grammes. 45 -|- 15 = 60 grammes. 

(About 1^ ounces.) (About 2 ounces.) 
6000 grammes ... 60 grammes. 60 -f 15 1= 75 grammes. 
(About 2 ounces.) (About 2J ounces.) 



At 30 Days. 
30 -f 30 = 60 grammes. 

(About 2 ounces.) 
45 -|- 30 = 75 grammes. 

(About 2J ounces.) 
60 -f 30 = 90 grammes. 

(About 3 ounces.) 



It is wiser always to accomplish first the proper digestion of the food, 
even if there is no gain in weight, and then, w^hen once the infant is digest- 
ing well, to increase the amount of the percentages of the different elements. 
At times when the infant is digesting well, and even gaining, it will suddenly 
cry so hard and with such evident hunger that an immediate increase in the 
amount of its food is not only indicated but demanded, no matter what its 
age or weight. In these cases the stomach has probably grown rapidly and 
out of its normal proportion to the age and size of the child, and a larger 
supply of food is what is needed. 

Om- clinical experience proves to us that the average infant in the early 
months of its life does not digest unmodified cow's milk. The exceptional 
instances where it is tolerated have their counterparts in the success of many 
other foods diverse in their composition, and only serve to prove that the 
human digestion can at times be tampered with w^ithout much apparent in- 
jury, and to emphasize the general rule that the chemistry of the food which 
will produce the best average result should be the chemistry of human milk. 
Cow's milk, therefore, should be carefully compared with the standard human 
milk in order that we should know how nearly it resembles it. This table 
(Table 59) is a comparison of the average human milk and the average cow's 
milk, the figm-es representing the later and more reliable analyses : 



TABLE 59. 

Woman's ^Milk directly from the 
Breast. 

Reaction Slightly alkaline. 

Water 87-88 

Total solids 13-12 

Fat 4.00 

Milk-sugar 7.00 

Proteids . 1.50 

Coagulable proteids . , Small proportionately. 
Coagulation of proteids 

by acetic acid .... Not perceptible in test-tube. 



Ash 



0.20 



Cow's Milk as ordinarily received about 
24 hours old. 

Slightly acid. 

86-87 

14-18 

4.00 

4.50 

4.00 
Large proportionately. 

Marked in test-tube ; greatest with 
pure milk ; less with milk diluted 
with water, and when 1 to 5 is 
not perceptible. . 
0.7 



236 PEDIATEICS. 

From this comparison we at once see that human milk and cow's milk 
differ as markedly from each other in their chemistry as they do in their 
clinical results as foods ; and^ as practically we must use cow's milk in sub- 
stitute feeding, our wisest course is to modify it until we have approached the 
chemistry of human milk as closely as possible. 

Before speaking of the various modifications of cow's milk which it is 
necessary to make in order that it may correspond to human milk, it will be 
well to say a few words about its properties as represented in the table 
(Table 59, page 235). 

Eeaction. — The reaction is stated to be slightly acid ; and this is the 
case whether it has stood twenty-four hours with ordinary care or whether 
it is tested directly from the udder. This I have determined by direct ex- 
periment : so that practically the same amount of modification will be correct 
for the first twenty-four or thirty-six hours, so far as the reaction is concerned. 

As it is wise in preparing a mixture for substitute feeding to make such 
a mixture approach as closely as possible in both taste and reaction to 
woman's milk, Harrington's experiments made at my request (Table 60) 
with lime water and ordinary cow's milk twenty-four hours old are im- 
portant. Lime water was the alkali used in these experiments because 
it is the most simple adjuvant which we can use for making cow's milk 
alkaline, the amount of lime contained in it being so small that its addition 
in even considerable quantity does not materially alter the amount of the 
total mineral matter. As small an amount as one-sixteenth part, when 
added to ordinary milk, will render it alkaline, so that for making an acid 
milk correspond in its reaction to woman's milk, lime water is of great value, 
as it apparently does not produce any other changes in the milk. In addi- 
tion to this, the taste of a mixture which is made from ordinary cow's milk, 
so as to correspond to the composition of woman's milk, is strikingly like 
that of woman's milk if it cdntain one-sixteenth part of lime water. 

Harrington has made an estimate by actual experiment of the amount 
of lime water which is needed to produce an alkalinity in a mixture such as 
I have just mentioned which would correspond to the alkalinity of human 
milk. This table (Table 60) shows the results of his experiments. 

TABLE 60. 

Amount of Lime 
Water in Mixture. Reaction. 

25 per cent ; Strongly alkaline. 

12.5 percent Still strongly alkaline. 

6.25 per cent Slightly but distinctly alkaline, and 

corresponding to woman's milk. 

It must be remembered that these proportions of lime water are those 
required for ordinary milk twenty-four hours old, a much smaller proportion 
being needed to produce the same results when the milk is treated with the 
care which I showed you was employed at the farm connected with the Milk- 
Laboratory. 



FEEDING. 237 

Water. — There is about one per cent, less of loater in cow's milk than 
in human milk. Chemical analyses invariably show so large an amount 
of water in human milk that it is evident that the infant is intended to 
take, and can best assimilate, a very dilute food. We must bear this fact 
in mind in preparing a substitute food, as the precaution of supplying a 
thoroughly diluted food is of extreme importance in managing the infant's 
feeding both in health and in disease. 

Total Solids. — There is about one per cent, more of total solids in 
cow's milk than in human milk. These solids in the milk are held partly 
in solution, partly in semi-solution, and partly in suspension. 

Fat. — The percentage of fat in the average cow's milk and in the aver- 
age human milk is the same. The glycerides of the fatty acids composing 
the fat in both cow's milk and human milk have been determined, yet our 
chemical and clinical knowledge of the nutritive value and digestibility 
of these, separately or collectively, has not arrived at a point where we can 
practically make use of this knowledge, and we therefore direct our atten- 
tion to regulating in a milk modification the percentage of the fat as a whole. 

Under this microscope you will see (Photo-micrograph, Fig. 61, page 
259) a thin layer of milk which is represented by a transparent medium 
permeated with small globules of fat. This fat is simply held in suspension, 
which enables us to separate it easily by mechanical means. It is, in fact, 
in a condition which marks the milk as an emulsion. 

Sugar. — The sugar which is present in the milk of all mammals is of 
the variety called milk-sugar, or lactose. It is a simple and uniform element 
to deal with. Its percentage in cow's milk is 4.5, and in woman's milk 7. 
It is held in solution in the milk. 

Regarding the kind of sugar which should be used in making up a sub- 
stitute food, we have certain questions to consider which would seem to be 
important. Cane-sugar has been, and still is, a favorite form with which to 
regulate this part of the solid constituents of the food. The reasons given 
for using it have been its preservative qualities, as seen in the manufacture 
of condensed milk, and the theory that it is not liable to set up excessive 
so-called lactic acid fermentation, with its consequent disturbance of diges- 
tion, as has been supposed to be the case with milk-sugar. Cane-sugar in a 
concentrated form, as it is found in condensed milk, seems to act as a pre- 
servative. But when it is diluted, as in its administration to the infant, 
cane-sugar ferments very readily, and in this respect has no advantage over 
milk-sugar. Reasoning from analogy, we should say that as milk-sugar is 
the onlv form of su^ar found in the milk of mammals, it is there for some 
good purpose, and that it is needed for the accomplishment of some process 
which takes place after the food has been swallowed. Both cane-sugar and 
milk-sugar are converted into glucose in the intestine. There seems, how- 
ever, to be some difference in the degree to ^\-liioh they can be used for 
purposes of nutrition before they are converted into glucose. So far as is 
known, whether in plants or in animals, cane-sugar is merely a reserve, and 



238 PEDIATRICS. 

cannot be used directly for nutrition. Milk-sugar, on the other hand, is 
probably not merely a reserve, but may possibly be utilized in the economy 
also for nutrition. Thus, Bernard has shown that seven grains of milk- 
sugar dissolved in an ounce of water could be injected under the skin of a 
rabbit without the subsequent appearance of sugar in the urine, while under 
the same conditions and in the same amount cane-sugar was found to be 
eliminated as foreign matter by the kidneys. 

Milk-sugar undergoes no direct alcoholic fermentation, but it changes 
readily to lactic (possibly acetic) acid in the presence of nitrogenous fer- 
ments, while cane-sugar easily undergoes alcoholic fermentation, but changes 
to lactic acid less readily than milk-sugar. Cane-sugar, moreover, takes on 
the butyric acid fermentation more readily than does milk-sugar. The 
bacillus ladis aerogenes (Escherich) is present in normal digestion, and acts 
on the milk-sugar to produce an organic acid which drives out the more 
noxious forms of bacteria, which by their presence would interfere with 
normal digestion. When milk-sugar is converted into glucose, we physio- 
logically have a gradual conversion into lactic acid, which may aid in the 
digestion of the albuminoids, thus giving us a very valuable addition to the 
means at our command for rendering modified cow's milk digestible. 

Jeffries says, in reference to the different actions of the various kinds of 
sugar in the digestive tract, that it is important to note that starch, dextrin, 
inulin, cane-sugar, and dextrose afford material for the butyric acid fermen- 
tation, while milk-sugar does this only after completed hydration. 

Escherich, in speaking of Brieger's bacillus, says, " Milk is coagulated 
with sour reaction first after several days (eight to ten) at the body tempera- 
ture. With exclusion of air this bacillus cannot grow either in milk or 
milk-sugar solution, but will in grape-sugar." 

We thus see that the milk-sugar offers less danger of the butyric acid 
ferment, which we know makes much trouble at times in the body, and 
that under certain conditions of the intestine it should be exempt from the 
assaults of Brieger's bacillus. 

When we consider that by means of heat we can practically put an end 
to the lactic acid fermentation, which may have begun to act upon the milk 
before it enters the stomach, it would seem that we are justified, on both 
physiological and bacteriological grounds, in using the same animal sugar 
in substitute feeding that is found in the infant's natural food, instead of 
introducing a vegetable sugar, which in milk is a foreign element. 

The dangers from lactic acid are, at any rate, much exaggerated by 
writers on this subject. 

Proteids. — The proteids of normal human milk have quite a wide 
range in their variation ; still, it is now well recognized that their average 
normal percentage is very much below that of cow's milk. Assuming that 
the percentage of proteids in human milk is 1.5, or between 1 and 2, it can 
be stated that the relation of the percentage of the proteids in cow's milk 
and in human milk is as 4 to 1.5. 



FEEDING. 



239 



The proteids represent the nitrogenous elements of milk. They are 
partly in solution and partly in suspension, as is seen on filtering through 
porcelain, where nearly all the caseinogen is left behind with the fat, while a 
small portion of the caseinogen and the other proteids is easily recognized 
in the serum. 

Of the total nitrogenous constituents of milk which are classed under 
the general term proteids, and of which the caseinogen and albumin are 
parts, the coagulable proteids in cow's milk are proportionately larger in 
amount than in human milk, so that under the same conditions a larger curd 
will be formed with the former than with the latter. 

Coagulation of Peoteids. — In conjunction with Dr. Harrington and 
Dr. Townsend I have made some careful experiments as to the relative 
coagulability by acids of woman's milk, cow's milk, and cow's milk diluted 
with lime water and barley water in various proportions. The coagulation 
by rennet was not found to be a satisfactory or reliable test. The experi- 
ments were performed in the following way. Equal volumes of the fluids 
tested were placed in a number of test-tubes. Ten drops of acetic acid were 
then added to each test-tube. Each test-tube was then inverted slowly 
three times, so as to insure thorough, equal, and uniform mixing in all. 

This table (Table 61) shows the results of these experiments, which may 
prove to be of considerable value : 

TABLE 61. 



Test-tubes. 
1. 
2. 
3. 
4. 
5. 



Coagulability of Milk hy Acetic Acid. 

Mixture. Coagulum. 

Woman's milk No curd perceptible to the eye. 

Cow's milk, raw Large curds. 

Cow's milk, boiled Same as 2. 

Cow's milk heated by steam to 100° C. (212° P.) Same as 2. 

Cow's milk 2 parts. | -p.^^^ ^^^^ 2. 

Water 1 Dart, i 

Cow's milk 2 

Lime water 1 

Cow's milk 2 

Water 

Cow's milk 2 

Barley water 1 

Cow's milk 1 

Water 4 

Fat . . 



part. 

P^^*^- \ Same as 5. 

part. J 

2 parts. I Slightly finer than 5 and 

1^ parts. J 

P^^*^- I Same as 7. 

} 



part, 
part, 
parts. 



Finer than 7 and 8. 



10. 



A mixture the 
composition 
of which was 



Sugar . 

Proteids 

Ash . . 

- Eeaction 



11. 



Total solids 

Cow's milk 1 part. 

Water 6 parts 



4.0 
7.0 
1.5 
0.2 
Slightly alka- 
line (6.25 per 
cent, of lime 
water.) 
12-13 



A very fine curd, finer than 9. 



Same as 1 : no curd percepti- 
ble to the eve. 



240 PEDIATRICS. 

When a few drops of mercuric nitrate solution were added to woman's 
milk and to cow's milk which had been diluted 1 to 5, as is represented 
in test-tube 11 in the table (Table 61), a fine coagulum was produced in the 
woman's milk, and a still finer one in the cow's milk. 

There was found to be practically no difference as to the rapidity of the 
coagulation of the different mixtures whether the milk was not heated or 
was heated to 100° C. (212° F.). 

Cow's milk taken directly from the udder was found to coagulate in just 
as large curds as when twenty-four hours old. It was found that there was 
practically no difference in the coagulation of raw, boiled, or steamed milk ; 
also that the size of the curd depends on the dilution of the proteids, rather 
than on any especial property belonging to the substance with which the 
dilution is made. With lime water the result was the same as with water 
in equal amount, and barley water shows only a fractional difference from 
the results obtained with plain water. 

Attenuants. — In order to ascertain if the statement is correct which 
is so often made, that ''attenuants act mechanically by getting between the 
particles of coagulum during coagulation and thus preventing their running 
together and forming a large compact mass," I have experimented as follows 
with various substances containing different percentages of starch : 

In each of six test-tubes of equal calibre, and containing 5 c.c. of hot 
water, 10 c.c. of milk were placed. In test-tubes 1, 2, 3, 4, 5, and 6 were 
added equal portions respectively of some starchy foods, cracker-crumbs, 
and bread-crumbs. The proteids were then coagulated as before with acetic 
acid, and the results were as seen in this table (Table 62) ; 

TABLE 62. 

Test-tube. Mixture. Coagulum. 

1. Hot water and milk Finest curd of all. 

2. Hot water and milk and starchy food Not so fine as 1. 

3. Hot water and milk and starchy food About like 2. 

4. Hot water and milk and starchy food Not so fine as 2 or 3. 

5. Hot water and milk and cracker-crumbs .... Not so fine as 4. 

6. Hot water and milk and bread-crumbs Not so fine as 5. 

There is no doubt that where no attenuant was added the curd looked 
decidedly finer, while where attenuants were used there was not a great deal 
of difference in the result obtained with the substances employed, except the 
possibly rather larger curd according as the attenuant contained a larger per- 
centage of starch. 

We may conclude, then, until something more definite is known concern- 
ing this rather theoretical method of treating the curd, that dilution with 
plain water is the most practical and efficient means at our command. 

As the predigestion of the proteids is frequently recommended by physi- 
cians when the infant's digestion is normal as well as when it is weakened, 
it is well to say a few w^ords about this predigestion in connection with sub- 
stitute feeding. 



FEEDING. 241 

Peptonized milk is cow's milk with its proteids partially or entirely pre- 
digested by means of the extract of pancreas and soda. There is no doubt 
that the proteids of cow's milk are at times a source of trouble to the 
infant's digestion, and that under certain circumstances they can with great 
benefit be treated by predigesting them for a time, and allowing a stomach 
which otherwise digests well to rest and recover its entire digestive power. 
It is of use also where a decided idiosyncrasy of the individual precludes 
the digestion of these constituents of the milk. In many cases the indiges- 
tion is attributed to a lack of power to digest proteids at all, while in fact 
the stomach is simply rebelling against an amount of proteids above the 
standard percentage, or against some other constituent. It would seerd 
that, for the average infant, this predigesting of the proteids is contrary 
to nature's teaching. There are certain natural functions which should be 
allowed to act as they do on human milk, and it seems irrational and con- 
trary to the laws of physiology not to encourage all the functions to act 
naturally, instead of forestalling their action and allowing them to fall into 
disuse and thus to be weakened. The infant's stomach is intended to digest 
proteids, and not to have the proteids digested for it. Clinically, also, the 
use of peptonized milk supports this view, for, so far as I know, no very 
brilliant results have been obtained from its use, except where the infant's 
digestion has been in an abnormal condition and one which has called for 
some decided relief from the proteid elements of milk. Peptonized milk, 
therefore, as a food for young infants is one which consists of too large an 
amount of digested proteids, too little sugar, and a very large over-propor- 
tion of mineral matter. 

Ash. — The constituents of the ash of cow's milk have been analyzed 
with comparative care and success. I have already, in speaking of the 
diiferences which exist between cow's milk and woman's milk, stated the 
differences which exist in their constituents and the elemental percentages 
of those constituents. This question of the percentage of the ash practi- 
cally does not enter into the modification of milk at the laboratory, as our 
knowledge has not yet advanced to that point where we can make use of 
what we know of these differences. 

There are a few other questions concerning the composition of cow's 
milk in relation to its proper modification for substitute feeding which it 
will be well to speak of here. 

Cow's milk, besides the elements which I have just spoken of and which 
I have represented in this table (Table 59, page 235), is supposed to contain 
a small portion of fibrinogen held in suspension. I have adopted the terms 
fibrinogen and caseinogen as recommended by Haliburton. They represent 
their respective elements as they actually exist in the milk before any change 
has taken place in them. After the milk has been drawn from the udder 
we have certain elements which we call casein, resulting from the caseinogen, 
and fibrin, resulting from the fibrinogen. 

Cow's milk is also supposed to contain urea and citric acid. 

16 



242 PEDIATRICS. 

In substitute feeding, the addition to modified cow's milk of some sub- 
stance, such as starch in various forms, is so frequently recommended that I 
think it will be well to state my opinion of this practice. 

This brings us to the consideration whether starch should be made a 
part of an infant's food. Physiologically, we know that during the first 
ten or twelve months of life the function of converting starch into sugar 
is in the process of development. It is true that a partial conversion of 
the starch can be performed at quite an early age, and, in exceptional cases, 
to a much greater extent than by the average infant. It is rational to 
suppose that when a function is being developed it should not be taxed 
with a trial of the use which will later be demanded of it. That is, a 
function develops more perfectly if its power is not exerted too early. 
With these facts before us, and simply recognizing that the best known food 
for infants, woman's milk, does not, under any circumstances, contain starch, 
I believe that starch should not form a part of the infant's food in the 
early months of its life. 

The question whether milk should be boiled or steamed is one which 
is not of much significance, and can be settled according to the fancy of the 
individual practitioner, a greater or less destruction of the bacteria contained 
in the milk taking place according to the degree of heat to which it is sub- 
mitted. My own experiments in comparing steamed with boiled milk show 
that the odor and taste of boiled milk are present when milk is steamed, 
but to a much less degree than in boiled milk ; also that while a thick scum 
is formed on milk boiled for twenty minutes, which is tenacious and does 
not disappear on shaking, only a very thin scum forms on milk steamed for 
twenty minutes, and that this is not tenacious and almost entirely disappears 
on shaking. 

Bacteriology. — A few matters concerning the bacteriology of cow's 
milk can best be considered in connection with the subject of substitute 
feeding. Respecting this question Dr. J. A. Jeffries very aptly remarks 
" that it is a curious fact that, while older people are chiefly fed on sterilized 
food, — that is, cooked food, — infants are fed on food peculiarly adapted by 
its composition and fluid state to offer a home for bacteria." In some 
experiments made by Jeflries agar-agar cultures were made before and after 
the different fluids were sterilized, and the colonies of bacteria were counted. 
His results coincide with those of previous experimenters, — namely, that 
steaming for fifteen minutes is suflicient to kill the developed bacteria, 
while a second steaming is necessary for complete sterilization. Out of one 
hundred and twenty lots of milk steamed but once, all but four or five 
showed distinct signs of change within a month, while the majority of those 
steamed twice did not change at all. 

Jeffries's experiments also show that spores develop slowly, and, indeed, 
rarely form, in milk, which, as he says, is an excellent medium for gro^vth, 
while spore-formation among bacteria, like seeding among higher plants, is 
a phenomenon of impaired growth. He also explains the preservation of 



FEEDING. 243 

some of the milk steamed but once by the absence of any enduring spores 
from the start. In an article of very great interest and value to the prac- 
tising physician " On the Bacteria of the Alimentary Canal/' Jeffries has 
reviewed, at my request, the work done by the various bacteriologists : 

" Miller, De Barry, and Escherich have shown that living bacteria are 
to be found in the stomachs of men and animals, and the former author 
has also clearly proved that bacteria can pass through the stomach into the 
intestines and live for a considerable time. . . . Of the morphology and 
biology of the forms found in the stomach little is known. The field is a 
new one, and the species have not been sufficiently described to enable others 
to recognize them with certainty. Miller has found five kinds which give 
off carbonic dioxide and hydrogen gas, lactic, acetic, and butyric acids being 
formed. . . . Of the flora of the intestines much more is known than of 
that of the stomach. The researches of Brieger, Vignal, Stahl, and Escherich 
have now proved that a large number of species may occur in the faeces. 
Brieger isolated two new kinds : one a micrococcus, which turns grape- or 
cane-sugar into ethylalcohol, with a trace of acetic acid ; the other the well- 
known Brieger's bacillus. This species occurs in the faeces in vast numbers, 
ferments sugar, and decomposes albumins. Vignal isolated ten species from 
the faeces, six of these also being found in the mouth. Of these some pro- 
duced acid fermentations and gas, but unfortunately they were not suffi- 
ciently studied to show their effects on digestion. . . . Escherich studied 
especially the faeces of infants, and found a large number of kinds of bacilli, 
among them a small bacillus capable of converting milk-sugar into lactic 
acid, carbonic dioxide and hydrogen gas being evolved, either in the presence 
or absence of air, a facultative anaerobic species, his bacillus lactis aerogenes. 
Escherich established, by the examination of a large series of cases, the fact 
that the kinds occurring in the faeces vary with the food, — that is, the in- 
testinal contents. . . . Starting at birth with the sterile meconium, consist- 
ing of mucus, epithelium, and the like, infection by the mouth and rectum 
quickly occurs, and in a short time almost any form may be found, but 
chiefly such putrefying forms as proteus vulgaris. 

" With the suckling of the infant and the substitution of the refuse of 
the milk and secretion of the digestive tract for the meconium, a sharp 
transition occurs. Instead of the generally distributed forms causing de- 
composition, only two kinds are regularly found, bacillus lactis aerogenes 
and Brieger' s bacillus ; the first chiefly in the upper parts of the intestine, 
the second in the lower parts. Passing on to the period of mixed diet, 
quite a number of forms appear, among them the streptococcus coli gracilis, 
the putrefying green fluorescing, a tetrad coccus, and several kinds of yeast. 
This brings us to the pith of the subject : Why are the flora so limited in 
the milk-eating infants and so diverse in others ? AVhat drives the forms 
found in the meconium out ? That they can live there is clear, as shown 
by their presence the day before. Again, what prevents forms so common 
with meat diet from gaining a footing? It is not the milk alone, for milk 



244 PEDIATRICS. 

is an almost universal food for bacteria, and all the kinds found in the 
intestines thrive in it. 

^^ According to Escherich, the bacillus lactis aerogenes and the milk diet 
keep out the other forms. 

" Formerly/' continues Jeffries, " even before the action of ferments and 
putrefactive processes were clearly understood, the significance of this ques- 
tion was seen. The chyme is a mass admirably adapted for putrefaction or 
fermentation, yet ordinarily but little of either occurs. It is an alkaline or, 
as in the milk-fed, acid mixture rich in albumins, fats, and the starch group, 
amply provided with water and warmth. Such a mixture outside the body 
at an equal temperature would quickly decompose. It was generally held 
that some preservative action was exerted by the digestive juices : Bidder's 
and Schmidt's dogs with biliary fistulse were supposed to explain the whole. 
These dogs, deprived of their bile, became emaciated, and suffered from diar- 
rhoea and decomposition of the intestinal contents. Thus it seemed clear that 
in the absence of the bile decomposition occurred, — that is, that the bile was 
a powerful germicide or germ-inhibitor. During the last few years, however, 
different results have been obtained in cases of biliary fistula. Rohmann's 
dogs did not suffer from diarrhoea or putrefaction in the intestines, hence 
it is clear that the bile is not the cause of prevention. The diarrhoea, if 
present, is due to the large amount of fat passed on to the lower intestines. 

" Maly and Emich ascribed value to the bile acids, especially the tauro- 
cholic, basing their results on crude methods ; and Lindenberger, really 
leaving the subject, attributed the action to the organic acids in combination 
with the bile. 

" All this argument and belief in the decided germicidal action of the bile 
occurred in the face of the well-known fact that bile itself will decompose. 

^^From a bacteriological stand-point. Miller has shown that a ten per 
cent, solution of bile, if anything, favors growth. Macfadyen has studied 
bile, bile salts, and bile acids in varying strengths. The only positive 
results were got with the acids ; these arrested the development of bacteria 
if sufficiently strong, especially taurocholic acid. Neither acid had much 
effect, and least of all on the forms causing putrefaction. Proteus vulgaris 
was only arrested by a strength of from one to two per cent. The patho- 
genic forms were arrested by a much smaller quantity, from one to one-half 
per mille. 

" It is thus clear that other causes must be sought for. One of these 
is to be found in the lack of oxygen in the intestines, as pointed out by 
Escherich and strangely forgotten by others. There is certainly very little 
free oxygen in the chyme, if any ; not only is it scarce in the food at the 
start, but is taken up by the chemical changes during digestion, and also by 
the intestines. This clearly must be a potent factor, for the majority of 
bacteria require a fair supply. Accordingly, many bacteria are found in the 
fseces which will grow in the air, as shortly stated by Macfadyen, and the 
mass of those isolated in the air are able to grow without it. 



. FEEDING. 245 

'^ This apparent contradiction, the absence of oxygen in the intestines, 
and the presence of both aerobic and anaerobic bacteria, is probably explained 
by the ability of the aerobic kinds to draw oxygen from oxyhsemoglobin. 
They thus breathe through the intestines, as it were, when in close contact 
with the walls, while the anaerobic kinds live in the mass of the chyme, and 
do not, so far as we know, reduce oxyhsemoglobin. 

" Escherich, though he points out the absence of oxygen, does not seem 
to give it full value, or rather forgets the subject in treating of the action of 
his laGtie acid bacillus. As before stated, this form is regularly found in 
great numbers in the upper part of the intestines of milk-fed children. 
Here it converts a considerable part of the milk-sugar into lactic acid, and 
thus prevents the other forms from growing, — most forms being susceptible 
to an acid reaction, and especially to the organic acids. The action of sali- 
cylic acid is known to all, and recent experiments, of which Macfadyen's 
(the last) are the best, show acetic, butyric, and lactic acids to be efficient 
germ-inhibitors in strengths of from one to one-half mille according to the 
species. 

" In milk-fed infants another point is the comparative inability of bac- 
teria to attack casein, so that the bacteria are literally starved. 

" We may therefore conclude that the bile acids, lack of oxygen, lack of 
suitable albumins, and the presence of organic acids are the causes of immu- 
nity from the putrefying and fermenting kinds of bacteria to which we are 
exposed. Certain forms are probably limited by the lack of water, — that 
is, of a fluid state, — doing poorly if unable to swim freely about. It must 
not, however, be supposed that bacteria are scarce in the intestines ; on the 
contrary, they form a large part of the dry substance of the faeces. 

" The ferments act by the production of various acids, chiefly derived 
from the milk-sugar. In small amounts, as in the case of the bacillus lactis 
aerogenes, the acid seems to be of benefit, and certainly does no harm, as it 
regularly occurs in healthy breast-fed infants. In large amounts, however, 
it must tend to over-acidify the contents of the intestines and interfere with 
the action of the digestive fluids.'' 

MILK-LABORATORY. — I shall refer again to this analysis (Analysis 
40, page 218) of the average milk of herds of cows when I am explaining 
the method by which those who are too far away from medical centres to 
make use of milk-laboratories may be enabled to modify milk with reason- 
able exactness from herds of common cows. Where, however, modification 
at the laboratory is used, according to the methods which I have described 
to you, constant special examinations of the milk-supply from the particular 
herd employed are necessary. 

I shall first describe the modification of the milk by means of the 
mechanism of the laboratory, and later speak of the more inexact methods, 
which may be designated as ''Home Modification" (Home Modification, 
page 276). 

As milk is one of the best means for the cultivation of bacteria, the 



246 



PEDIATRICS. 



laboratory should be situated in a healthy locality. It should be as free as 
possible from contaminating influences, should be kept absolutely clean, and 
every aseptic precaution against the harboring or development of pathogenic 
organisms should be taken. 

From the moment that the milk is delivered from the farm at a temper- 
ature of about 4.4° C. (40° F.) it should be watched over and cared for with 
scientific accuracy during the whole process of the modification which it under- 
goes in the laboratory. The milk-rooms should be cool and free from dust, 
and isolated, so far as possible, from other parts of the laboratory. 

Fig. 50. 




Milk-room. 



There should also be an entirely separate room where the returned pack- 
ages and all articles received from the homes of the consumers should be 
directly brought from the street or wagons, and where these articles can be 
immediately sterilized in apparatus reserved for this purpose. 

The modifying materials used in the laboratory should be carefully kept 
for use in glass vessels, and at a temperature of about 4.4° C. (40° F.), to pre- 
vent the growth of bacteria. The reason for this is that milk modified from 
materials free from bacteria is better for the infant than milk in which the 
bacteria have been destroyed by heat. Therefore the utmost care is neces- 
sary in all parts of the process and in every department of the laboratory. 

A special room should be provided for the milk-modifiers who are to 
put up the mixtures required by each prescription. 



FEEDING. 



247 



There should also be a room where the milk is separated by means of 
machinery and where it can be tested and steamed. 

The office at the laboratory should be entirely separate from these work- 
rooms, so that customers coming to leave their orders should not go near 
the materials used for modification and thus possibly contaminate them. 

It is necessary, also, that all odors should be excluded from the work- 
rooms, as milk absorbs odors very quickly. 



Fig. 51. 



Ventilating-fan. 




Power. 



Water-still. 
Separating-room. 

It is hardly necessary to say that the employees of a laboratory, whether 
they be in the office or in the work-rooms, should be intelligent and interested 
in their work. 

I have explained to you in a general way the chief requirements of a 
milk-laboratory. I will now take you to the Laboratory and explain to you 
on the spot the various details which must be understood by the physician 
so that he can intelligently order what is best fitted for the infant under his 
charge. 

Milk-Room. — AVe are now in the milk-room (Fig. 50, page 246), where 
the milk is received on its arrival from the farm. 

The milk from the farm is delivered here in the milk-room within a few 
hours from the time of the milkinsr. You saw how it was aerated at the 



248 



PEDIATRICS. 



farm and cooled to about 6.66° C. (44° F.), and you now see that on its ar- 
rival at tlie milk-room its temperature is found to have been held by means 
of ice during the transportation below 7.22° C. (45° F.). You see how it 
has been transported in these boxes and how the man in charge of the room 
has had it placed in the tanks of ice-water. 

This milk, as a result of the especial manner in which the cow^s have 
been fed and cared for and the selection of them according to the proper 
breed, may be said to have an almost uniform percentage of its elements. 
Even at those times of the year when the percentages of the different ele- 
ments of milk commonly vary from changes in the pasturage and in the 
habits and surroundings of the animals, the milk of these cows, w^hich have 
their food supplied to them in stated rations at one time of the year as well 
as another, is not subject to the elemental variations which occur in the milk 
of ordinary cows. 

Having seen here in the milk-room the methods by which the milk is 
treated and is kept uncontaminated, we will visit the separating-room, where 
the milk is taken to prepare it for the modifying clerk. 

Separating-Eoom. — This room (Fig. 51, page 247) is arranged and 
cared for in very much the same way as is the milk-house at the farm. The 
w^alls are of white tile, and the ceilings are of material which can be washed 
and scrubbed. The floor is of asphalt, impenetrable to water, and is kept 
thoroughly moistened and free from every kind of dirt and dust. 

Ventilator. — In addition to the precautions against pathogenic germs, 
which I have already explained to you, the air of the separating-room is 
kept fresh and pure by means of this ventilator which you see in the corner 
of the room. It consists of a large steel fan, w^hich 
revolves at the rate of two thousand times a minute, 
and by the force of its current carries away any flies 
or particles of dust which may come within its reach. 

Separator. — Here is a piece of machinery of great 
delicacy, called the Centrifugal Separator. 

This separator is made to revolve six thousand eight 
hundred times in a minute, and works with such search- 
ing effect on the milk that only a small percentage 
(0.13) of fat remains in the separated milk. 

The utility of the separator, however, does not con- 
sist wholly in its absolute withdrawal of the fat from 
the milk and in providing cream as fresh as to time 
as is the separated whole milk : it accomplishes tw^o 
other very important results. First, by its great cen- 
trifugal force it separates from the cream and the 
separated milk any dirt or foreign matter of any kind 
which necessarily gets into every milk, and thus pro- 
vides at once a practically clean milk, a most important result from a bac- 
teriological point of view. Secondly, the resulting cream has an almost 



Fig. 52. 




Centrifugal separator. 



FEEDING. 



249 



stable percentage of fat, — sixteen per cent., — the importance, of course, of 
this being in its stability, and not in its special percentage. 

Still, — We also have in this room (separating-room, p. 247) a still for 
freshly preparing each day distilled water. 

In this next room you will see the steam-power (represented to right of 
separating-room, p. 247) which runs the ventilating-fan, the separator, the 
water-still, and the sterilizer which I shall presently describe to you. 

MoDiFYiNG-RooM. — We are now in the modifying- room, where the 
milk is tested, where the materials for preparing the food are brought from 
the diiferent rooms when needed, and where the modification of the milk is 
completed. 




Modifying-room. 

Babcock Milk-Tester. — To be doubly sure that the chemistry of the 
milk is what we suppose it to be from the uniform nature of the primal 
milk-supply, we take advantage of the knowledge which we have concern- 
ing the changes most likely to take place in certain elements of the milk. 

The percentage of the proteids, of the sugar, and of the mineral matter 
in the milk of a herd of this kind, where uniformity in the feeding is the 
rule, is not apt to be appreciably affected. But the percentage of the fat in 
individual cows differs from day to day, and thus slightly afltects the per- 
centage of the fat in the milk of the herd. 

The fat, then, being the element by wliich we know whether each milk- 
ing gives a uniform product, we test this element by means of what is called 
the "Babcock Milk-Tester." I have here on this table the Babcock 



250 



PEDIATKICS. 



machine, and I will have the percentage of the fat in a specimen of this 
morning's milk tested for you. 

The peculiar feature of this method of ascertaining the percentage of fat 
in milk, as described in the Wisconsin Experiment Station, Bulletin No. 
24, July, 1890, consists in placing these test-bottles containing the acidi- 
fied milk in a centrifugal machine, by the rapid revolution of which the 
fat is made to separate quickly and completely. The milk is acidified in 
order that the proteids, casein and fibrin, may be changed to soluble acid 
albumins, which offer less resistance to the rising and aggregation of the 
fat-globules. 

Approximately equal volumes of milk and commercial sulphuric acid of 
1.82 specific gravity are mixed in a test-bottle with a long graduated neck. 
This pipette, delivering about 17.5 c.c. of milk, and this measuring cylinder 

Fig. 54. 




Babcock milk-tester. 

for the acid, are used. The acid is in this large bottle to the right of the 
machine. The bottles are whirled for several minutes at a temperature of 
93"^ C. (200° F.) in a horizontal wheel making from seven to eight hundred 
revolutions per minute. This wheel is surrounded by a copper jacket, 
which may be filled with hot water for heating during the test. The sepa- 
ration of fat by gravity alone is not complete even when the bottles are left 
standing for several hours. By centrifuge, however, a perfect separation is 
accomplished in a few minutes. If whirled at once, no heat need be applied, 
as that caused by the strong acid and milk is sufficient. After whirling, 
the bottles are filled to the neck with hot water, returned to the machine, 
and whirled for one or two minutes longer, after which they are filled with 
hot water to about this seven per cent, mark, and the machine is again 
turned for a short time, the temperature being kept up by means of a lamp 
or by filling the jacket with hot water. The fat separates and its percentage 
is noted while still liquid, preferably at about 65° C. (150° F.), the readi^tr 



FEEDING. 



251 



giving the percentage of fat directly without calculation and being easily 
taken to 0.1 per cent. 

This daily testing of the fat enables the modifier to preserve the accuracy 
of his material, and to correct any variation in the percentage of the cream 
as it comes from the separator. 

The milk this morning shows four per cent, of fat, and therefore we 
conclude that we are dealing with the usual uniform milk expected to 
come from the farm. The average and almost stable analysis of this milk 
throughout the year shows a percentage of fat of 4.00, and is the basis on 
which the office clerk makes the calculation by which the percentage of the 
fat called for in the various prescriptions is exactly obtained. Knowing the 
exact percentages of this milk, the office clerk can, by a simple mathematical 
formula, give the required directions on the modifying clerk's formula for 
obtaining whatever percentages of the other elements the physician may 
call for. 

Here are the figures (Analysis 46) which have been found to result from 
many analyses of the milk of the herd which you saw at the farm : 

ANALYSIS 46. 

Fat 4.00 

Sugar 4.30 

Proteids 4.00 

Ash 0.65 

Total solids 12.95 

Water 87.05 

100.00 

I have also had placed here on another table for your inspection the 
modifying materials used for making up the prescriptions. 




Modifying materials. 



In this large glass jar on the left side of the table is the stable cream 
obtained from the separator, whicli is used in obtaining the prescribed per- 
On the right side of the table is another large glass jar 



centage of fat. 



252 PEDIATRICS. 

which contains the separated milk, also of stable percentage, obtained from 
the separator, and which is used for obtaining the different percentages of 
the proteids as called for in the prescription. 

We must, of course, allow that the cream as well as the separated milk 
contains its own definite percentages of sugar, proteids, and mineral matter. 
This analysis (Analysis 47) shows the percentages of the fat, sugar, and 
proteids in this cream and separated milk : 



ANALYSIS 47. 



Cream .... 
Separated milk 



Fat. 


Sugar. 


Proteids. 


16.00 


4.00 


3.60 


0.13 


4.40 


4.00 



To provide the means for adjusting the percentages of the sugar which 
are called for, a carefully prepared twenty per cent, solution of milk-sugar 
and distilled water is used, and is kept in this large glass jar which stands 
beside the cream-jar. The reaction of the food is adjusted by means of the 
lime water which you see in this large glass jar beside the separated milk, 
and which is freshly prepared every day. 

The other jars on the table contain specimens of cream of different per- 
centages, and preparations of oats, barley , and wheat, which are freshly pre- 
pared at the Laboratory each day, and which can be used for infants when 
they are old enough to have starch added to their food. 

With these modifying materials the modifying clerks combine each 
infantas food according to the prescription before them, and pour it into the 
glass tubes from which the infant is to nurse. These tubes, which you see 
standing in their baskets on the modifying clerks' table, have been especially 
devised as the most practical for general use, are adapted both for transpor- 
tation and for use as nursing-bottles, and are easily cleansed. 

There are two sets of clerks. (See page 249.) One set is engaged in modi- 
fying the milk according to the prescriptions. As soon as the tubes are filled 
by the modifying clerks they are passed on to the stoppling clerks, who im- 
mediately seal them with aseptic non-absorbent cotton especially prepared 
for this purpose, and place them in these baskets adapted as to their com- 
partments to the number of feedings ordered for the special infant. Here 
are some baskets which hold eight, some which hold ten, and some which 
hold four tubes. The tubes are kept on tube-racks within easy reach of the 
modifying clerks. Each basket has its own label attached to it, with the 
address of the person to whom it is to be sent. 

The rule of absolute cleanliness is carried out in every possible detail, 
from the table on which the materials are combined to the dress and hands 
of the clerks. 

When the milk has been separated, recombined according to the pre- 
scriptions, stoppled, and placed in the respective baskets, the baskets are 
taken from the modifying-room to the separating-room. 

Sterilizer. — We will now return to the separating-room (page 247) 



FEEDING. 



253 



and see the baskets placed in this large sterilizer (Fig. 56), which has a 
capacity of 240 kilogrammes (500 pints). 

The sterilizer is so arranged that the steam which passes through it can 
be regulated so as to produce any degree of heat required up to 100° C. 
(212° F.). This is accomplished by a regulator attached to the steam-pipe, 
and, as you see, the man in charge of the heating of the food, by keeping his 
hand on the regulator and his eye on the thermometer which is fitted to the 
sterilizer, can subject the baskets and the tubes in them to whatever degree 
of heat is ordered, and of course for the length of time required. 

After the food has been heated, the baskets are taken out of the steril- 
izer and placed in the cooling-tank, where the temperature of the food is 
reduced to 13.3° C. (38° F.). 



Fig. 56. 



Capacity, 500 pints. 




Fig. 57. 




sterilizer. 



Special sterilizer. 



The baskets are then placed in the deli very- wagon, which quickly 
conveys them to their various destinations. 

Where a special prescription at an unusual time of the day is called for, 
it is heated in this hood and special sterilizer (Fig. 57). 

When the baskets are delivered at the homes of the consumers, the 
baskets and tubes of the previous day are returned to the Laboratory. 
When they reach the Laboratory they are taken directly from the street to 
the wash-room (Fig. 58), which is entirely shut off, as I have before told 
you, from the rest of the Laboratory. 

Wash-Room. — Here in the wash-room (Fig. 58), in order to carry out 
absolutely the aseptic precautions, the baskets and everything which has 
been returned to the Laboratory are placed in this special sterilizer belonging 



254 



PEDIATRICS. 



Fig. 58. 
Aseptic precautions. 



to the wash-room. You observe that the baskets and tubes are just being 
taken out of the sterilizer. The bottles, after being sterilized, are thoroughly 

washed in these tubs, which are especially 
adapted for this purpose, in a solution of soda 
and water. All the tags and stoppers are 
destroyed after sterilization. The baskets 
are of woven willow, and are easily kept 
sterile. 

In this way, always guarding against 
possible infection of all kinds, the Laboratory 
enables us to make use of the chemical and 
bacteriological knowledge which we have ac- 
quired in connection with the feeding of in- 
fants, and fulfils the requirements of that 
system of substitute feeding which up to the 
present time has proved to be the best. 

You will now have an opportunity of 
seeing the returned baskets and tubes actually 
steamed in the sterilizer (Fig. 59). 

The doors of the sterilizer are tightly 

clamped, and Mr. Gordon has just ordered 

the steam to be turned into it. 

Modification. — We will suppose that you wish to prescribe some 

modified milk for an infant four months old, with normal digestion and of 




Wash-room and sterilizer for returned 
materials. 



Fig. 59. 




Sterilizer, containing returned baskets and tubes. 

normal weight and general development. The regular prescription-blank 
issued by the Laboratory can be used if you have one, but, of course, a 
milk-prescription can be written as you would write a prescription for a 



FEEDING. 



ZOO 



drug. Here is one of the prescription- blanks that I am in the habit of 
using at this special Laboratory, and which I will fill with some supposed 
directions. 



Pkesckiption Blank. 



B 



Per Cent. 



Fat . ... 


4 


00 


Milk-Sugar . . . 


7 


00 


Proteids .... 
Mineral Matter . 


. . 1 


50 


Lime Water . . 












Special Directions. 





For Whom Ordered. 



Date. 



Eeaction Slightly alkaline. 

Number of Feedings .... 7 

Amount at each Feeding . . 135c.c. (^4J) 

Heated for 20 minutes. 

Heated at ^^2° ^• 



Kemarks 



Infant's Age ? 



4 months. 
14 pounds. 



Signature. 



M.D. 



I shall direct the percentage of fat to be 4, that of sugar 7, that of the 
proteids 1.5. I shall order the reaction to be slightly alkaline. 

In regard to the question of the reaction, it can be left to the milk- 
modifier, as we leave to him the carrying out of other directions contained 
in the prescription. If the milk brought to the Laboratory on the special 
day when we are sending our prescription has been produced from cows 
fed, as I have previously described, on sugar-beets, the milk may be already 
sufficiently alkaline for an infanf s digestion when normal. If, on the con- 
trary, the milk has its usual acid or amphoteric reaction, the milk-modifier 
will make it slightly alkaline, in accordance with oiu- prescription and 
according as the milk of the special day has a greater or less acid reaction. 
For this pm-pose lime water should be used, as being the best material 
and as least likely to do harm. If, however, the infants digestion is not 
normal and we wish to prescribe a precise amount of lime water, we can do 
so by writing for whatever percentage we choose, as we do for the other 
elements of the milk. In modifvino; the milk which comes from the farm 
connected with this Laboratory, as a rule, one-twentieth part of lime water 
(five per cent.) is sufficient to make the reaction correspond to that of nor- 
mal human milk. By referring to this table (Table 60) you will see what 
the percentage of lime water should be in order to obtain a greater or less 
degree of alkalinity. The hydrate of lime is said to be soluble to the ex- 
tent of 1 part in 778 parts of water at a temperature of 15.5° C. (60° F.). 
This would make one oimce of lime water to contain rather more than 
0.03 (1 grain) of Ca02H2 (hydrate of lime). 



256 PEDIATRICS. 

I shall write for seven feedings, and make the amount at each feeding 
135 c.c. (4 J ounces). 

I showed you at a previous lecture (Lecture VIII., p. 221) that the 
milk from the farm connected with the Laboratory has proved to be com- 
paratively free from bacteria, and that it would probably be unnecessary to 
destroy the few bacteria which exist in it if the infant could be immediately 
fed here in the Laboratory. As this is not possible, and as the milk has to 
be transported from the Laboratory to the homes of the consumers at various 
distances, I have found it better to heat the milk to 75° C. (167° F.). 
This temperature, as I have already explained to you, is sufficient to kill 
those developed bacteria which would be of any harm to the digestion of 
the infant, and at the same time is below 77.2° C. (171° F.), the point 
at which coagulation of the proteids is supposed to take place. We thus 
obtain a practically pure fresh milk, uncooked and sterile. We therefore 
write in our prescription 75° C. (167° F.). If, however, the milk is to be 
sent a long distance, if the weather is hot, or if the milk-supply has to last 
more than twenty-four hours, a higher degree of heating can be used, 
according to the wish of the prescriber. Thus, 100° C (212° F.) is a tem- 
perature used for these purposes at the Laboratory. Where, again, we 
wish the milk to be absolutely sterilized, as may be the case when we are 
preparing it for an ocean voyage or for a trip across the continent, not 
only a high degree of heat, 100° C. (212° F.), but two or three heatings, 
with intervals of some hours, are necessary for this complete sterilization, 
and this can be called for in our prescription. The length of time during 
which the milk should be heated, as a rule, can be left to the judgment of 
the superintendent. I have already shown you in this table (Table 55) that 
ten minutes is often sufficient to kill the developed bacteria and to make 
this especial milk practically sterile. Experience, however, has proved that 
during transportation the milk is often exposed to temperatures conducive 
to the further development of bacteria, and that practically the bacteriologi- 
cal results which we obtain in the Laboratory do not entirely hold when 
the milk is exposed to these varied conditions of transit. As a rule, there- 
fore, from twenty to thirty minutes is the proper time to heat mixtures of 
modified milk sent from the Laboratory. 

I shall also, for record in the Laboratory and for reference later, state 
on the prescription the infant's age and weight. 

Finally I shall date the prescription, write on it the address where the 
food is to be delivered, and sign it. 

This prescription is now handed to the clerk in the office. The clerk 
copies it into this book, which records each day's feeding of each individual 
infant, and then translates the physician's prescription into such form as can 
be readily understood by the modifying clerks. Of course this form may 
vary in different parts of the world, according as the metric or the apothe- 
cary system is in use. In the work of this especial Laboratory, although 
the prescriptions are written by the physicians in the metric system, it has 



FEEDING. 



257 



beeu found more convenient, when delivered to the patrons of the Labora- 
tory, to have the amounts expressed in ounces and drachms. The office 
clerk, after translating the metric percentages into ounces and drachms, 
copies it on to a blank of this form, which is called the modifying clerk's 
prescription : 



Modifying Clerk's Prescription. 



No 

Name of Infant 

Age of Infant 4 mos. wks. 

Weight of Infant 14 lbs. oz. 

Address 



Send by at 



.o'clock. 



Physician'' s Prescription. 

Per Cent. 



Fat 

Milk-Sugar . . 
Proteids . . , 
Mineral Matter 
Lime Water 



Clerk'' s Formula. 



Modifying Cream . . . 

Modifying Milk 4 

Sugar Solution 8 

Lime Water 1 

Water 8 



Oz. Dr. 

7i 7 

4i 7 

8i3 

5 

6 



Total 31 : 4 



No. of Feedings .... 
Amount at each Feeding 

Heated at 

Time in Sterilizer . . . 



4 J ounces. 
167° F. 
20 minutes. 



Kemarks. 



Put up by 

Date 

Month 



17 
18 
19 
20 
21 



6 22 

7 23 

8 24 

9 25 

10 26 

11 27 

12 28 

13 29 

14 30 

15 31 
16 



Copied 189 by. 



This prescription is then placed in the hands of the modifying clerk, 
who combines the different elements of the prescription by means of the 
elemental materials which have been brought into the modify ing-room from 
a different part of the Laboratory, and which I have already described. 

I have requested physicians to write their prescriptions within certain 
limits as to the percentages of the fat, sugar, and proteids, and to allow the 
mineral matter for the present to regulate itself. The limits ^A'hicli up to 
the present time the Laboratory has found it necessary to place on the pre- 
scriptions for the milk-modifiers, and within which the modifying clerk 
is supposed to put up the prescriptions, are as is shown in this table 
(Table 63) : 

17 



258 



PEDIATRICS. 



TABLE 63. 

Fat from 0.03 to 36.00 

Sugar from 0.87 to 20.00 

Proteids from 0.22 to 4.00 

There is not much doubt that in the fature more and more exact results 
will be obtained, representing definite percentages of still wider limits. The 
results obtained from combining the modifying materials used by the modi- 
fying clerks have so often been proved to be practically correct, that we can 
assume that when we write a prescription we shall obtain in return a product 
which in its various elements comes within a fraction of one per cent. 

I have arranged in this table (Table 64) figures which will aid you in 
writing for such percentages of the fat, sugar, and proteids as can be ob- 
tained at the Laboratory : 

TABLE 64. 
Practical Limits of Milk-Modification which can he accomplished in the Laboratory. 

I. 
Low Fats. 

Fat 0.03 0.04 0.08 0.12-16 

Sugar 2.00 3.00 4-5.00 6.00-7.00 

Proteids 0.75 1.00 2.00 3.00-4.00 

II. 

Low Sugars. 

Sugar 0.87 1.40 2.12 3.50-4.30 

Fat 2.00 3.00 3.50 4.00 

Proteids 0.75 1.00 2.00 3.00-4.00 

III. 

Low Proteids. 

Proteids 0.22 0.34 0.45 0.53 

Fat 2.00 8.00 4.00 4.50 

Sugar 2.00 3.00 4 00-5.00 6.00-7.00 

I'icj- 60- You see that in I. I have taken the 

^^ lowest percentage of fat which can practi- 

cally be used at the Laboratory and have 
combined it with various percentages of 
sugar and of proteids. In II., in like 
i^a ^^.^---'^^s^ manner, I have taken the lowest percentages 
-^ — '^"^^ " ^^ of the sugar which can be combined with 
these various percentages of fat and pro- 
teids. Finally, in III. I have made the 
same calculations for the proteids. 

Other materials can also be obtained at 
the Laboratory on the physician's prescrip- 
tion for older infants and children, notably 
preparations of oats, barley, and wheat, which you see this young woman 
(Fig. 60) preparing in a special apparatus devised for steaming these cereals. 
When a physician orders cereals to be prepared at the Laboratory, he is 




FEEDING. 259 

enabled by this apparatus to obtain exact preparations as to the percentages 
of the constituents of any cereal foods. This is accomplished by employing 
an analysis of the special cereal ordered^ and, with distilled water as a 
diluent, regulating the time the heating shall be maintained with ^^live 
steam'' around the porcelain crocks. 

The question having arisen whether the emulsion of milk which is used 
for modification is interfered with or destroyed by modification, I have 
answered it in the following way : 

Under each of these four microscopes there is a drop of milk strongly 
magnified. 

Under the first microscope (Fig. 61) you will see a drop of milk as it 

Fig. 61. 




Cow's milk. 

came from the cow, unmodified and unchanged, except as it might have been 
affected by transportation from the farm. 

The analysis (Analysis 48) of the milk from which this drop was taken 
is as follows : 

ANALYSIS 48. 

Cow's Milk. 

Fat 4.04 

Sugar 4.55 

Proteids 4.15 

Ash '. . . . 0.71 

Total solids 13.46 

Water 86.55 

100.00 



260 PEDIATRICS. 

Under this second microscope (Fig. 62) is a drop of a mixture which 
has been so treated as to represent the same analysis (Analysis 48) as that 

Fig. 62. 




Cow's milk separated and recomposed 
Fig. 63. 




Human milk. 



FEEDING. 261 

of the original whole milk^ and which in fact is the original whole milk as 
seen in Fig. 61, which has been separated and recomposed. 

You will notice that the emulsion of the recomposed milk is quite as 
good as that of the original whole milk from which it was separated. 

Under this third microscope (Fig. 63) I have placed a specimen of 
human milk. 

The analysis (Analysis 49) of this milk was sent to me in order that I 
should have a food modified to correspond to it, to be used for the purpose 
of a mixed feeding : 

ANALYSIS 49. 

Human Milk. 

Fat 2.67 

Sugar 6.37 

Proteids 2.69 

Ash 0.15 

Total solids 11.88 

Water 88.12 

100.00 



Under this fourth microscope (Fig. 64) is a specimen of cow's milk modi- 
fied to correspond to the human milk which is under the third microscope 

(Fig. 63). 

Tig. 64. 




Modified milk. 



You see that the emulsion corresponds almost exactly : so tliat there is 
no question that it is not injurious, so far as the emulsion is concerned, to 
separate the elements of milk and then recombine them. 



262 PEDIATRICS. 

I shall now take you back to the office and show you the various forms 
of apparatus which are provided for feeding the infant in its home. I have 
had some of them placed on this table (Fig. 65). 

Fig. 65. 




In the left of the picture is a basket holding eight tubes of a capacity of six otinces each. In front of 
this basket is a four-ounce tube in a wire stand. In the middle of the picture is a tin apparatus for 
warming the milk at the time of feeding. An alcohol lamp is shown beneath the warmer, and a tube 
of milk and a thermometer for testing the tempyerature of the milk are in the tin-warmer. Next to and 
to the right of the tin-warmer is a tube with a capacity of eight ounces. It is enclosed in a white worsted 
cozy, has the rubber nipple in place, and is supported in a wire stand. In the right of the picture is a 
basket containing six tubes with a capacity of eight ounces each. In front of this basket are an eight- 
ounce tube and a four-ounce tube. 

This apparatus is very simple and practical for transportation. A 
wicker basket, divided into a number of compartments corresponding to 
the number of feedings which are to be sent to the infant, has been found 
to be the most practical. These baskets with their tubes can be placed, 
as you saw, directly in the sterilizer, and are not harmed by the heat to 
which it is necessary to expose the food. 

This tin receptacle can be placed above an alcohol lamp ; the water in it 
is to be on a level with the height of the milk which is contained in the tube, 
and the tube is submerged in the water. It has been found necessary to 
take the temperature of the food by means of a thermometer placed directly 
in the tube. No rule can be laid down by which the temperature of the 
water-bath determines that of the milk, unless the tubes are of uniform 
thickness and the milk uniform in quantity and temperature when placed in 
the bath. The thermometer must be washed in sterilized water with the 
greatest care, both before and after it is used. The food when given to the 
infant should have a temperature of from 36.6° to 37.7° C. (98°-100° F.). 

As in direct feeding from the breast the food which the infant receives has 
the same temperature at the end of the feeding as at the beginning, we should 
copy this provision of nature and not allow the temperature of the food to 
vary during the time it is being taken. To accomplish this end, this white 
worsted cozy can be used. The cozy is warmed at the same time that the milk 
is being heated, and the tube when placed in it is prevented from cooling. 



FEEDING. 



263 



Thus the infant receives a food of unvarying temperature throughout the 

whole of the feeding;. ^ 

^ EiG. 66. 

i nave here also to 
show to you the various 
means which are used in 
transporting the food 
when it has to be sent 
long distances. Here is 
a transportation-box (Fig. 
66), which is used in cold 
weather, when ice is not 
necessary to preserve the 
freshness of the milk. 

This box (Fig. 67) is 
one which can be used 
in hot weather, and has 
proved to be of great prac- 
tical utility. It admi- 
rably serves the purposes 
of an express box and of a home refrigerator. The ice, as you see, is 
packed in a metal compartment in the middle of the box, and the tubes are 
placed, each in its own compartment, around the sides of the ice-receptacle. 

Pig. 67. 




Transportation-box, containing basket and tubes. 




Ice-box, holding twelve tubes. Receptacle for ice in centre of box. Laboratory prescription-blank 
in front of box, and packing-paper under end of open lid. 

I shall now call your attention to two cases which were fed under my 
direction at the Milk -Laboratory during the first year of their lives, and 
which merely illustrate the changes which naturally would be made during 
this period in the food of a healthy infant. 



264 



PEDIATRICS. 



The first case (Case 91) was a male, born November 18, 1892. This 
table (Table 65) shows the record of its weight and food durmg its first 
year: 

TABLE 65. 

Showing Management of the Food and Increase in Weight of a Healthy Infant {Case 91) 
during the First Fifty- Two Weeks of its Life. 





Weeks 






Amount 


Percentages 


DF Food. 




Date. 


of 


Weight. 




at each 










Life. 






Feeding. 
























Fat. 


i Sugar. 


Proteids. 


Lime Water. 








Grams. 


Lbs. 


Oz. 


C.c. 


Oz. 












November 18 . . 


1 


3752 


8 


6 


30 


1 


2.00 


6.00 


1.00 


5.00 




u 




2 




























3 
4 


. . . 


• • 


• 


"45 


n 


3.00 


6.00 


1.00 






u 






5 






, 


75 


^ 


4.00 


7.00 


1.00 


10.00 




December 2J 






6 


4284 


'9' 


9 


90 


3 












(( 






7 






















u 






8 




. 






. . 


. 


. . . 


. . . 


5.00 




January 1§ 






9 


6944 


i5' 


8 


105 


H 


















10 
11 






















it 






12 
13 








120 


4 












February 17 






14 


6048 


i3' 


7 


135 


^ 


4.00 


7.00 


2.00 






i< 






15 




















/-^ 


u 






16 




















^ 


u 






17 























March 17* 

u 
ii. 
il 
u 






18 
19 
20 
21 
22 


6748 


15 


1 


150 


5 










CO 

d 
& 


April 21 [ 

a 






23 
24 
25 

26 


7308 


16 


5 


165 


5J 












May 18 '. 






27 


7604 


16 


12 


180 


6 


4.00 


7.00 


2.50 






u 






28 






















il 






29 























"... 

"... 






30 
31 


- 


















f 


June 22 . 

u 






32 
33 
34 


7840 


17 


8 


210 


7 


4.00 


7.00 


3.00 


12.50 


1 
1 


(( 






35 




















s 


u 






36 




















^ 








37 
38 




• • 




• • 




4.00 
3.50 


7.00 
6.50 


2.50 
1.50 


10 00 


1 


"... 






39 








180 


*6' 


4.00 


7.00 


2.00 


5.00 




August 17 

u 






40 
41 
42 
43 
44 


8820 

. . . 


i9* 


1*1 


^25 


7i 


4.06 
4.00 


6.00' 
5.00 


'2*56 
3.00 


10.00 

12.50 

10.00 

5.00 




u 






45 






















u 






46 






















u 
u 

(( 

ii 






47 

48 
49 
50 
51 


. . . 






• • 


• • 


Wh 


ole mi 
ole mi 


Ik. 

Ik and 


oat jelly. 




November 9 




52 


9870 


22 



















The grammes in the third column have been reduced to pounds and ounces on the basis 
of 28 grammes to the ounce, and the fractions of the ounce have been disregarded. 



FEEDING. 



265 



The next case (Case 92) was a female, born November 1, 1892. This 
chart (Chart 4) shows the line of growth in its weight from birth to the 
fifty-second week of its life : 



— 






















IP. 


s 


1 

ta 


Bt 


rth 


I? 


^ 


rramm 

1 


es 


















1 


Bateof Birth Nov.lst. 


5 


11 


i 


g 


*. 


; 


§ 


y 


y 


i 


i 




1 


i 


i 


t 


1 


o 






I 


i 




g 


<o 


o 


i 


i 


§1 


Actual Weight 


1 " 


= 


Gram's 


& 


o 




























































1 


3,180 


7 


1 


Nov 


1 




























































2 


3.180 


7 


1 


" 


8 




























































3 


3.180 


7 


1 


" 


15 




v 






















































4 


3,480 


7 


10 


>' 


22 




-^ 
























































5 


3,520 


7 


14 


'•■ 


29 






\ 






















































6 


3,730 


8 


5 [Dec. 


6 








v 




















































7 


3,980 


8 


14 


■■ 


13 










\ 






















1 


























8 


4,160 


9 


4 




20 










\ 


\^ 
















































9 


4.340 


9 


10 


" 


27 












\ 


V 












































10 


4.590 


10 


4 


Jan.l 3 1 














^ 


V 












































11 


4,870 


10 


14 




10 




1 












^ 


V 










































12 


5.060 


11 


4 


" 


17 


















\ 










































13 


5,270 


11 


12 


„ 


24 




























































14 


5,560 


12 


6| V 


31 






















V 


s. 




































15 


5,870 


13 


1 


Tet 


7 
























A 


^ 


































16 


6,070 


13 


8 


" 


14 


























N 


^ 
































17 


6,300 


14 


1 


" 


21 




























\ 
































18 


6,370 


14 


4 


- 


28 




























\ 
































19 


6,510 


14 


8 


Mar 


7 




























\ 






























20 


6,650 


14 


13 




14 






























■\ 


s, 




























21 


6,920 


15 


7 


" 


21 
































\ 




























22 


6,980 


15 


9 


- 


28 
































' 


^ 


























23 


7.150 


15 


15 


Apr. 


4 


































\ 


























24 


7.240 


16 


2 


.. 


11 




































\ 
























25 


7,560 


16 


14 




18 






































\ 






















26 


7,600 


16 


15 


" 


25 






































\ 


k 




















27 


7,800 


17 


6 


May 


2 






































/ 


> 




















28 


7,730 


17 


4 


.. 


9 








































s 




















29 


7,840 


17 


8 


•• 


16 








































N 


L 


















30 


8,070 


18 





■• 


23 










































\ 


















31 


8.160 


18 


3 


.. 


30 










































\ 


















32 


8,190 


18 


4 


Tune 


6 












































s 
















33 


8.490 


18 


15 


- 


13 












































i 
















34 


8,470 


18 


14 


" 


20 














































\ 














35 


8,700 


19 


6 


•• 


27 














































> 














36 


8.762 


19 


8 


U.uly 


4 
















































\ 












37 


8.824 


19 


u 


>. 


11 
















































\l 










38 


8,950 


19 


14 


>' 


13 






















1 




































39 


8,970 


20 





'• 


25 




























































40 


8,980 


20 


1 


A-ug. 


1 




1 
























































41 


9,060 


20 


4 


•^ 


8 


















































\ 










42 


9.140 


20 


6 




15 


















































v 










43 


9,340 


20 


13 


" 


22 










1 






































/ 


> 
^ 








44 


9.170 


20 


8 


■" 


29 


















































\ 


L 








45 


9.290 


20 


12 


Sep. 


5 




















































\ 








46 


9,340 


20 


13 




12 




















































V 








47 


9,470 


21 


2 


•■ 


19 




















































\ 


s 






48 


9.640 


21 


9 




26 






















































\ 






49 


9,630 


21 


8 


Oct. 


3 






















































\ 






50 


9,740 


21 


10 




10 
























































\ 




51 


9.870 


22 







17 
























































I 




52 


9.890 


22 


1 


■■ 


24 


. 


-3 -J 


00 


oo 


CO 


CO 


o 


o 


^ 


- 


K- 


CO 


CO 


to 


:^ 


5: 


^ 


at 


55 


^ 


!^ 


oo 


s 


G 


g 


s 


to 


eo 




















3 00 


o 


00 


o 


oo 


o 


00 


o 


00 


o 


OJ 


tn 


G 


Ol 


G 


o 


00 


M 


Ol 


!^ 


-o 


s 


<£> 


^^ 


p 


■(k 


w 


O 


' 


31 


^eth 


itl. 


~^ 


nlhs 


























w 


igh 


ta 


B 


rth 


7 Pounds 


10 


unc 


ll- 


u 
















1 












266 



PEDIATRICS. 



I have also arranged a table (Table 66) recording the quantity and 
quality of this infant's (Case 92) food during the first year : 



TABLE 66. 

Showing Management of the Food and Increase in Weight of a Healthy Infant [Case 92) 
during the First Fifty- Two Weeks of its Life. 















Percentages of Food. 




Weeks 






Amount 




Date. 


of 
Life. 


\YpT/tlTirr. 


at eacti 








Feeding. 


Fat. 


Sugar. 


Proteids. 


Lime Water. 








Grams. 


Lbs. 


Oz. 


C.c. 


Oz. 












November 1 . . 


1 


3180 




1 
















November 8 




2 


3180 




1 


60 


2 


2.00 


5.00 


1.00 


5.00 




November 15 




3 


3180 




1 


60 


2 


4.00 


7.00 


1.00 






November 22 




4 


3480 




10 


90 


8 


4.00 


7.00 


1.00 






November 29 




5 


3520 




14 


75 


2i 


8.00 


7.00 


1.00 






December 6 




6 


3730 


8 


5 


. 




8.00 


6.00 


1.00 






December 13 




7 


3980 


8 


14 






8.00 


7.00 


1.00 






December 20 




8 


4160 


9 


4 


'96 


'3* 


4.00 


7.00 


1.00 


10.00 




December 27 




9 


4340 


9 


10 


105 


H 


4.00 


7.00 


1.25 


5.00 




January 3 . 




10 


4590 


10 


4 


, . 




4.00 


7.00 


1.50 






January 10 . 




11 


4870 


10 


14 
















January 17 . 




12 


5060 


11 


4 
















January 24 . 




13 


5270 


11 


12 
















January 81 . 




14 


5560 


12 


6 














'-^ 


February 7 . 




15 


5870 


18 


1 


120 


4 








12.50 


^ 


February 14 




16 


6070 


13 


8 


135 


^ 








10.00 




5;; 


February 21 




17 


6300 


14 


1 


. 






. 




5.00 


CO 


February 28 




18 


6370 


14 


4 














^ 


March 7 . . 




19 


6510 


14 


8 

















March 14 






20 


6650 


14 


18 


150 


6 


4.00 


7.00 


2.00 




2o 


March 21 






21 


6920 


15 


7 














i>- 


March 28 






22 


6980 


15 


9 














s3 


April 4 . 






23 


7150 


15 


15 














S-i 


April 11 . 






24 


7240 


16 


2 
















April 18 . 






25 


7560 


16 


14 














CD 


April 25 . 






26 


7600 


16 


15 














'^ 


May 2 . . 






27 


7800 


17 


6 




- 










1 


May 9 . . 






28 


7730 


17 


4 

















May 16 . 






29 


7840 


17 


8 














t 


May 23 . 






30 


8070 


18 





180 


6 










a 


May 30 . 






31 


8160 


18 


8 














a 


June 6 . . 






32 


8190 


18 


4 














TS 


June 13 . 






33 


8490 


18 


15 


195 


H 


4.00 


7.00 


2.50 




-2 


June 20 . 






84 


8470 


18 


14 
















June 27 . 






35 


8700 


19 


6 
















July 4. . 






36 


8762 


19 


8 














§ 


July 11 . 






37 


8824 


19 


11 














fe 


July 18 . 






38 


8950 


19 


14 
















July 25 . 






39 


8970 


20 



















August 1 . 






40 


8980 


20 



















August 8 . 






41 


9060 


20 


8 
















August 15 






42 


9140 


20 


6 
















August 22 






43 


9340 


20 


18 
















August 29 






44 


9170 


20 


7 
















September 5 




45 


9290 


20 


11 
















September 12 




46 


9340 


20 


18 
















September 19 




47 


9470 


21 


2 
















September 26 




48 


9640 


21 


9 
















October 3 . 




49 


9630 


21 


7 
















October 10 . 




50 


9740 


21 


10 


. 




4.00 


6.00 


3.00 






October 17 . 




51 


9870 


22 









Wh 


ole mi 


Ik. 






October 24 . 




62 


9890 


22 


1 


• • 




Wh 


ole mi 


Ik and 


oat jelly 





The grammes in the third column have been reduced to pounds and ounces on the basis 
of 28 grammes to the ounce, and the fractions of the ounce have been disregarded. 



FEEDING. 267 

I shall also mention a few cases which have a practical bearing on the 
method of substitute feeding by means of milk-laboratories. 

The first case illustrates how important it is to be able to vary the per- 
centages of the diiferent elements of the milk, and to know that we are 
obtaining these variations exactly as they are ordered. 

An infant (Case 93) was being nursed by its mother, who was healthy and who had an 
abundance of breast-milk. Their summer home was by the sea-side, in a healthy situation, 
and the infant was surrounded with everything that could be desired for perfect hygiene. 
The infant during the first two months of its life nursed well, throve, and was perfectly 
quiescent in its daily life. When it was three months old, the mother was very much 
worried by some trivial family matters and did not take much exercise. The infant now 
began to have colic, and, although it gained in weight, it was very restless and cried con- 
tinuously. An analysis (Analysis 50) of the mother's milk at this time gave the following 
result : 

ANALYSIS 50. 

Fat 2.69 

Sugar 6.15 

Proteids . 3.71 

Ash 0.17 

Total solids 12.72 

Water 87.28 

100.00 

The indications for treatment were, of course, to lessen the amount of mental disturb- 
ance in the mother and to make her exercise more. The mother having followed these 
directions, the symptoms in the infant soon became less severe. After a few days, how- 
ever, the unfavorable symptoms returned, and it was found that the mother had not been 
exercising and was again mentally disturbed. As it seemed impossible to regulate the func- 
tion of the mammary gland under these circumstances, it was decided to feed the infant 
from the Milk-Laboratory. The following prescription (Prescription 5) was ordered : 

Prescription 5. 

B Fat 3.50 

Sugar 6.50 

Proteids 1.00 

Keaction Slightly alkaline. 

Heated to 75° C. (167° F.). 

Eight tubes, each holding 90 c.c. (3 ounces). 

The infant digested this food perfectly, had no colic, and again became tranquil. As, 
however, it only made a slight gain in weight during the first two or three weeks of this 
substitute feeding, I changed the prescription to the following one (Prescription 6) : 

Prescription 6. 

R Fat 4.00 

Sugar , 7.00 

Proteids 1.50 

On taking this food the infant began to make regular gains in weight, and continued 
to thrive until it was four months old, when it was brought back to its city home, where it 
was subjected to many of the annoyances which you will so frequently see occurring in the 



268 PEDIATRICS. 

families which you take care of, and which, though somewhat disastrous to the infant, tend 
to advance our knowledge of substitute feeding. The annoyances which I refer to were, in 
this especial case, as follows. The infant was surrounded with too much excitement, and 
was exposed to unnecessary changes of temperature in its home. During the process of 
removal from the sea-side to the city it caught a slight cold, and had intestinal symptoms 
characterized by loose discharges from the bowels and undigested food. This condition was 
easily obviated in a few days by simply changing the prescription at the Laboratory to the 
following one (Prescription 7) : 

Prescription 7. 

R Fat ...... 2.50 

Sugar 5.50 

Proteids 1.00 

Lime water 10.00 

Under this treatment the food was again fairly well digested, the discharges lessened 
in frequency and they were of a better character. The infant, however, during this sick- 
ness had lost over 224 grammes (about J pound) in weight. 

At this juncture the grandmother of the infant so influenced the mother that she 
insisted upon having a wet-nurse procured at once. Although I did not approve of this 
change, the family were so urgent in their demands for a wet-nurse that I procured one for 
them. This wet-nurse was nursing her own infant and another infant at the Infants' 
Hospital. Both infants were thriving in every way. An analysis (Analysis 51) of this 
wet-nurse's milk gave the following results : 

ANALYSIS 51. 

Fat 2.92 

Sugar 6.20 

Proteids 4 62 

Ash 0.16 

Total solids 13.90 

Water 86.10 

100.00 

The milk for this analysis was taken from the middle of the nursing. The percentage 
of proteids was so high that I did not dare to allow the foster-infant to be put to the breast 
at once. I therefore endeavored to regulate the percentages of the elements of the wet- 
nurse's milk in the usual way. At the end of two days another analysis (Analysis 52) of 
her milk was made, with the following result : 

ANALYSIS 52. 

Fat . . 3.39 

Sugar 5.95 

Proteids 4.78 

Ash 0.21 

Total solids 14.33 

Water 85.67 

100.00 

The extraordinarily high percentage of proteids in this analysis made me absolutely- 
refuse to allow the foster-infant to begin with its nursing from the wet-nurse. The family, 
however, were very impatient, and argued that, as the other two infants were gaining in 
weight, digesting well, and looking remarkably ruddy, it must be a good milk which they 
were receiving from the wet-nurse. 



FEEDING. 269 

Two days later, although the foster-infant was decidedly improving on the substitute 
food from the Laboratory, it happened to lose 30 grammes (about 1 ounce) in weight, and 
the family then insisted that this wet-nurse should be tried. Another analysis of the wet- 
nurse's milk was then made, and showed that the percentage of the proteids had been 
reduced to between 3 and 4. 

I had already endeavored to find other wet-nurses whose milk would better correspond 
to what the infant needed, but was unsuccessful in obtaining any the analysis of whose 
milk showed the percentage of the proteids to be below 3. 

I have here the analyses (Analyses 53 and 54) of the milk of two of these wet-nurses, 
which you may perhaps like to see : 

ANALYSIS 53. 

Fat 3.88 * 

Sugar 6.55 

Proteids 3.14 

Ash 0.14 

Total solids 13.71 

Water 86.29 

100.00 

ANALYSIS 54. 

Fat 3.39 

Sugar 4.50 

Proteids 4.70 

Ash ". . 0.18 

Total solids 12.77 

Water 87.23 

100.00 

The first wet-nurse was then brought to the foster-infant's home, and the infant was 
put to the breast. It absolutely refused to take the breast for twelve hours, although it 
was crying with hunger. Finally it was induced to nurse, but immediately after the 
nursing had an attack of colic. These attacks of colic were more or less severe and oc- 
curred after each nursing. The infant soon appeared to like the milk and took it eagerly 
at the regular nursing intervals. In twenty-four hours from the time when the infant 
began to nurse its bowels were again afifected. The number of discharges became frequent, 
and the milk evidently was not being digested well. These conditions lasted for several 
days, when it was found that the infant had lost over 480 grammes (about 1 pound) in weight. 
As the severity of the colic was increasing, and as the infant had lost its color, the mother 
agreed to have the feeding by the wet-nurse discontinued. I then wrote the following pre- 
scription (Prescription 8) to be put up at the Laboratory : 

Prescription 8. 

R Fat 2.00 

Sugar 5.00 

Proteids 1.00 

Lime water 10.00 

To be heated to . . 75° C. (167° P.) 

This mixture was given to the infant. In twenty-four hours the number of discharges 
from the bowels grew less, and in a few days became almost normal. It began to gain in 
weight, and, though seeming very hungry, looked better and ceased to have colic. 

The prescription was then changed to the following one (Prescription 9) : 



270 PEDIATBICS. 

Peescription 9. 

R Fat 3.00 

Sugar 6.00 

Proteids 1.00 

Lime water 5.00 

On taking this food the infant began to make regular gains in weight, but still seemed 
hungry, so that at the end of another week the prescription was changed to the following 
one (Prescription 10) : 

Prescription 10, 

R Fat 4.00 

Sugar 7.00 

Proteids 1.50 

The infant now improved steadily. It made the normal average daily gains in weight, 
and soon recovered its color and former strength. From this time it continued to thrive. 

This case is interesting in many ways. It was very evident that a per- 
centage of proteids over 3 was more than this especial infant could digest. 
It therefore had to be weaned from its mother. The wet-nurse^s milk, 
which was agreeing perfectly with her own infant and with another infant 
which she was nursing at the hospital, had a percentage of proteids between 
3 and 4. As I knew from my experience with the mother's milk that this 
high percentage of proteids would not agree with the infant, I was not sur- 
prised to find that, instead of agreeing with it, it made it sick. This case 
substantiates the statement which I have made in an earlier lecture (Lecture 
VII., page 180), that, while there are many varieties of good milk, there are 
also many infants who cannot thrive on them all, but only upon such as 
suit their individual digestive powers. 

It is interesting also to record in this case that, as the infant grew older, 
it was found that the percentage of the proteids could be increased in its 
food without harming its digestion, and that by the time it was eight months 
old it was having in its food percentages of proteids between 3 and 4, the 
very percentages which caused such serious digestive disturbance when it 
was younger. When it was ten months old it was able to digest 4 per cent, 
of proteids in its food. 

This case as a whole so well illustrates the use of the Milk-Laboratory 
that it is hardly worth while to multiply instances of its value. I will, 
however, give the record of the treatment of some twins (Cases 94 and 95) 
that have recently come under my charge, showing the utility of feeding by 
means of modified milk. 

These infants were born at term, but were as weak and emaciated as though they had 
been premature. One of them had a convulsion when it was a few hours old, and the 
other's circulation was very deficient and showed evidence of a cardiac souffle over the base 
of the sternum for some days. This class of infants is very apt to die unless their food is 
carefully regulated at once, and the great lack of equilibrium of the percentages of the 
elements of the maternal milk in the early days of life is often most disastrous in its effects 
on the hypersensitive condition of the gastro-enteric tract at this age. 

Here is a table (Table 67) showing the condition and the treatment of these infants in 
the first fifty days of their lives : 





Case 


94. 








TABL 

Showing the Details of the First Fifty I 




Percentagks of Foods. 


AMOUNT 
AT K.YCH 

Feeding. 


Intervals 

OF 

Feeding. 


Weight. 


D. 



L] 


Remarks, 


Fat. 


Sugar. 


Proteids. 


Lime 
Water, 


Very weak. Emaciated. 

Brandy 3 drops every 3 hours. 
Cardiac iiiurniur at base of 


Equt 
lim 


il parts 
e watei 


cow's mi 


Ik and 


Co. 
4 


Dr'ms, 
1 


2 hours. 


Gram's. 
1«16 


Lbs. 
4 


Oz. 



steriiuni 


Breast-milk. 










i 

i 

i 

'. 
i 
I 
i 
I 
t 
1 
I 

I 
i 
I 

i 

i 
( 
( 

( 

I 

1 

( 
( 
( 
i 
( 
i 

I 
I 

( 

( 
< 






• • 




Colic. Loose movements. 




IG 


4 




Vomitin"". 




















. . . 




• • 




Icterus neonatorum from 8th 


Breast o m i f t e d 










dav to 3oth dav. Cord fell 


1.50 


5.00 


0.75 


10.00 


20 


5 










on 8th day. 
]5randy 6 drops every 6 hours. 
Very feeble. Kespirations 
irregular. 


2056 


4 


8 


1 
1 
1 








































• ' • 


2176 
2176 
2270 
2510 


4 
4 

5 
5 


12 

12 



8 


1 
1 
1 
















1 
1 
1 


Vomitini^. 




































1.25 


0.00 


0.75 


10.00 






2630 
2570 
2540 
2495 
2510 
2510 
2540 
2525 
2540 
2555 
2525 
2540 
2540 
2495 
2555 
2600 
2630 
2660 
2660 
2690 
2705 
2720 
2739 
2769 
2724 
2754 
2784 
2799 
2814 
2829 
2889 
2904 


5 
5 
5 
5 
5 
5 
5 
5 
5 
5 
5 
5 
5 
5 
5 
5 
5 
5 
5 
5 
5 
5 

? 

6 
() 
6 
6 
6 
6 
6 
6 


12 

10 

9 

n 

8 
8 
9 

I' 

9 

9 

7h 

91 

ir 

12 
13 
13 
14 

14^ 
15 

n 
n 

0" 

1 

2 
6 


1 








9 


]\[uch flatus. Six loose green 

dejections. 
Cries a great deal. Very 

hungry. Brandy 3 drops 

every 3 hours. 
























82 


8 


9 










2 
9 








. . . 






2 
2 
2 

9 


















i.50 


G.OO 












1.00 


10.00 






8 


Lo.ss Vomiting, 






3 
8 


Fiecal discharges fewer in 


2.00 


00 


1.00 


5.00 


48' 


' 12 


3 
3 


number und look better. 










3 

3 

R 


























56 


14 


s 












8' 












64 


16 


4 












4 




2.50 


0.50 


1 00 


' 5.00 


, 




4 

4 
4 
















4\ 


10 feedings in '24 liours. 














4 






. . . 










4' 
















4 




8.00 


0.50 










/{' 


Fif'cal discharges well digested 
and of good color. Thriving. 


1 00 


5.00 


64 


16 


6i 



























67. 

of Llf 


e of Cases 94 and 96 ( 


Twin. 


0- 






Case 95. 




■F 1 

FE.| 

1 

2 

3 1 

4 i 
5 

6 

1 
8 

9 

1 
2 
3 
4 
;5 
.6 

I 

,9 

1 

!2 
3 
[4 
5 
6 
7 

9 

1 
2 
3 
4 
5 
6 
17 
8 
9 

1 

;2 

I 

15 

!6 

I 

(9 


Weight. 


Intervals 

OF 

Feeding. 


Amount 

AT EACH 

Feeding. 


Percentages of Foods. 




Fat. Sugar. Froteids. 
Equal parts cow"s mi 


Lime 
Water. 

Ik and 


Re.mauks. 


Gram's. 
1782 


Lbs. 
8 


Oz. 
14 


2 hours. 


C.c. 
4 


Dr'ms. 
1 


Hemorrhage from cord. Con- 
vulsions. Very weak. Ema- 
ciated. 

Brandy 3 drops every 3 hours. 








lime water. 
Breast-milk, . . . 
Breast-milk. . . . 
Breast-milk. . . . 
Breast-milk. . . . 
Breast fimittefl 










i 


16 


4 


Colic. Loose fyecal dejections. 
Cord fell on 4th dav 






















20 


5 


Icterus neonatorum from 8th 
dav to 3Cth dav Less colic 








1.50 


5.00 75 


10.00 












Brandy 6 drops every hours. 
Very feeble. Kespirations 
irrei>'ular. Fewer faecal de- 


2056 


4 


8 






















. . . 


jections. 






























. 




2056 
2056 
2176 
2420 


4 

4 
4 
5 


8 
4 






. . . 


. . 






















Vomiting. 












10.00 










. 


1.25 


6.00 


0.75 


Less vomitinf 


2480 
2510 
2480 
2495 
2480 
2510 
2510 
2495 
2510 
2525 
2510 
2540 
2510 
2495 
2540 
2570 
2600 
2615 
2645 
2660 
2675 
1 2724 
2739 
2724 
2769 
2784 
2844 
2874 
2904 
2874 
2919 
2949 


5 
5 
5 
5 
5 
5 
5 
5 
5 
5 
5 
5 
5 
5 
5 
5 
5 
5 
5 
5 
5 
6 

f 

6 
6 
6 
6 
6 
6 
6 
6 


7 
8 

\^ 

7 

8 

8 

71 

8" 

8i 

8^ 

9 

8 

71 

9- 
10 
11 
lU 
12| 
13 
131 

0"^ 





1.^ 

2^ 

4 

5 

6 

5 

6.^ 

1h 




32" 


" §■ 








• • • 


Very weak. Icterus pro- 
nounced. Vomitino' occa- 






















sionally. Four or five faecal 
discharges dailv and not well 














digested. 


• ■ 


















l'.50 


'e.oo 


1.00' 


io.oo 


FcTcal discharges fewer and 
better digested. 
















48' 


' 12 


2.00 


6.00 


1 00 


5.00 


Very hungry. 








. . . 




























56 
64' 


14 
' 16 ' 






























No icteru.-. Much stron2:er. 












, , . 


No vomitinsi;. Fiocal dis- 














char*^'es fewer and loi>k 






2.50 


6.50 


1.00 


5,00 


better. 














10 feedings in 24 hours. 












. . . 








































1.25 


' 5^00 




72 


18 


3.00 


6.50 


Fn?cal dojoctions well digested 
and of good oi>lor. Thriving. 





























FEEDING. 271 

It may be instructive for you to look over a few of these prescriptions 
which I have sent to the Laboratory at different times, as they will give you 
a very fair idea of the simplicity and precision of substitute feeding. 

Prescription 11. 
A girl 6 years old; duodenal jaundice [functional). 

R Fat 0.50 

Milk-sugar 6.00 

Proteids 3.00 

Lime water 10.00 

Send 12 tubes, each 4 ounces. 

Prescription 12. 
A boy 6 weeks old; healthy. 

R Fat 3.00 

Milk-sugar . 7.00 

Proteids 1.50 

Keaction Slightly alkaline. 

Heated to 75° 0. (167° F.). 

12 tubes, each 2 ounces. 

Prescription 13. 
A boy 6 months old ; healthy. 

R Fat . . , 4.00 

Sugar 7.00 

Proteids 2.00 

Eeaction Slightly alkaline. 

Heated to 75° C. (167° F.). 

8 tubes, each 6 ounces. 

Prescription 14. 
A girl 4 months old ; proteid digestion weak. 

R Fat' 4.00 

Sugar 7.00 

Proteids 0.75 

Lime water 5.00 

Heated to 75° C. (167° F.). 

8 tubes, each 4 ounces. 

Prescription 15. 
A boy 6 months old ; sugar digestion weak. 

R Fat 3.00 

Sugar 4.00 

Proteids 2.00 

Lime water 5.00 

Heated to 75° C. (167° F.). 

8 tubes, each 6 ounces. 

Prescription 16. 

A girl 4 months old ; summer diarrhoea. Food has to be sent to a distant town by express. 

R Fat 2.00 

Sugar 5.00 

Proteids 1 00 

At time of each feeding add lime water 3 drachms. 

Heated to 100° C. (212° F.). 

20 tubes, each 1 ounce and 1 drachm. 



272 PEDIATRICS. 

In this case the diarrhoea had not been sufficiently studied to determine 
whether it was putrefactive or fermentative^ so that a safe general prescrip- 
tion was sent to begin with. The lime water had to be introduced at each 
feeding on account of the 100° C. (212° F.) heating, necessitated by the 
hot weather and the distance to be sent. If the lime water had been intro- 
duced at the Laboratory and heated to 100° C. (212° F.) with the food, a 
reaction would have taken place between the lime and the sugar, and the 
mixture would have turned brown and have had a peculiar taste. 

Feeding of Average Infants Born at Term. — When an infant is 
born at term, is of normal development and weight, and is healthy, I am 
in the habit of regulating the quantity of its food according to the figures 
which I have arranged in this table (Table 57, page 234). These figures, 
however, are intended only to be provisional until by experiment the proper 
amount for the individual has been ascertained. 

The quality of the food which I begin with is usually as shown in the 
following prescriptions (Prescriptions 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 
27, 28, 29). Where these prescriptions are used the infant is supposed to 
be digesting well and gaining in weight progressively. 

Prescription 17. 
For the first twenty-four to thirty-six hours of life. 
R Milk sugar, five-per-')ent. solution, in sterilized distilled water. 

Prescription 18. 
First week. 

R Fat 2.00 

Sugar 5.00 

Proteids 0.75 

Keaction Slightly alkaline. 

Heated to 75° C. (167° F.). 

Prescription 19. 
Second week. 

B Fat 2.50 

Sugar 6.00 

Proteids 1.00 

Keaction Slightly alkaline. 

Heated to ..'... 75° C. (167° F.). 

Prescription 20. 
Third week. 

R Fat . . 3.00 

Sugar 6.00 

Proteids 1.00 

Reaction Slightly alkaline. 

Heated to . . 75° C. (167° F.). 

Prescription 21. 
Four to six weeks. 

R Fat 3.50 

Sugar 6.50 

Proteids 1.00 

Reaction Slightly alkaline. 

Heated to 75° C. (167° F.). 



FEEDING. 273 



Prescription 22. 

Six to eight weeks. 

R Fat S.50 

Sugar 6.50 

Proteids 1.50 

Keaction Slightly alkaline. 

Heated to 75° C. (167° P.). 

Prescription 23. 
Two to four months. 

B Pat 4.00 

Sugar 7.00 

Proteids 1.50 

Keaction Slightly alkaline. 

Heated to 75° C. (167° P.). 

Prescription 24. 
Four to eight months. 

R Pat 4.00 

Sugar 7.00 

Proteids 2.00 

Eeaction Slightly alkaline. 

Heated to 75° C. (167° P.). 

Prescription 25. 
Eight to nine months. 

R Pat 4.00 

Sugar 7.00 

Proteids „ 2.50 

Keaction Slightly alkaline. 

Heated to 75° C. (167° P.). 

Prescription 26. 
Nine to ten months. 

R Pat 4.00 

Sugar 7.00 

Proteids 3.00 

Keaction Slightly alkaline. 

Heated to - 75° C. (167° P.). 

Prescription 27. 
Ten to ten and a half months. 

R Pat . 4.00 

Sugar 5.00 

Proteids 3.25 

Keaction Slightly alkaline. 

Heated to 75° C. (167° P.). 

Prescription 28. 
Ten and one-half to eleven m,onths. 

R Pat 4.00 

Sugar 4.50 

Proteids 3.50 

Keaction Slightly alkaline. 

Heated to 75° C. (167° P.). 

18 



274 PEDIATRICS. 

Prescription 29. 

Eleven to eleven and one-half months. 
R Unmodified cow's milk. 

At about the tenth or eleventh month I usually begin to give at first 
one and then two meals daily of equal parts of oat jelly, prepared at the 
Laboratory, with plain cow's milk heated to 75° C. (167° F.), and a little 
salt added according to the infant's taste at the time of the feeding. (Prep- 
aration of cereals described in Lecture X., p. 281.) Freshly prepared barley 
or wheat can, if preferred, be given with milk at this age. 

In the twelfth month I usually accustom the infant to taking a little 
bread one day old with its milk, and to be fed from a spoon, so that by the 
time it is a year old it is taking bread and milk for its breakfast and supper, 
and oat jelly and milk for the three middle meals. 

COLOR OF F^CAL DEJECTIONS AS INFLUENCED BY THE PERCENTAGE 

OF FAT IN THE FOOD. 

I have considered it of some scientific interest to record the color of the 
fsecal discharges which corresponds apparently to the percentage of fat in 
human milk and in the corresponding modified milk. On these two nap- 
kins (Plate III., 3 and 4, facing p. 112) are the normal yellow dejections 
of two infants (Cases 96 and 97) who are being nursed by their healthy 
mothers and are themselves digesting well and thriving. 

Here are also two napkins (Plate III., 8 and 9, facing p. 112) on which 
are the normal yellow dejections of two infants (Cases 98 and 99) who are 
being fed on a modified milk which is supposed to correspond to average 
human milk. The percentages of the fat, sugar, and proteids in this modified 
milk are respectively 4, 7, and 1. The infants are digesting well and thriving. 

You will notice the striking resemblance in color and consistency 
between these fsecal discharges resulting from human milk and from modi- 
fied milk, where the percentage of fat is 4. 

I have here also to show you the fsecal discharges (Plate III., 7, facing 
p. 112) of a healthy infant (Case 100), fed on a modified milk having a 
percentage of 3 for its fat, 6 for its sugar, and 1 for its proteids. You see 
how much lighter the color of the yellow is. 

This change of color is still more strikingly illustrated in this napkin 
taken from this fourth infant (Case 101, Plate III., 6, facing p. 112), where 
its modified milk was composed of fat 2 per cent., sugar 5 per cent., and 
proteids 1 per cent., and where you see the resulting fsecal discharge has a 
very much lighter yellow^ color than is the case with the others. 

During the last three years I have been able to test the value of this 
Laboratory by the feeding of nearly three thousand infants, and my experi- 
ence has been controlled in the practical use of this system by about four 
hundred physicians. The number of infants that have ' been fed from the 
Laboratory each day was about two hundred. 



FEEDING. 275 

I myself believe that by the establishment of these laboratories a new 
era has been entered upon in the province of infant feeding, and one which 
will enable us to produce results which have never before been obtained. 

Before leaving the subject of milk-laboratories, I should like to impress 
upon you that the establishment of laboratories for the modification of milk 
has to so great a degree been accomplished by the extensive knowledge of 
the subject, the great experience, the unwavering determination, and the 
enthusiastic efforts of Mr. G. E. Gordon, that physicians, as well as all 
others who are interested in the welfare of infants, must always acknowl- 
edge their indebtedness to him for the great work which he has carried 
to so successful an issue. 

The first milk-laboratory for the exact modification of milk that has 
been established in the world is the one which I have just shown you, and 
was opened to the public in 1891 here in Boston, under the name of the 
Walker-Gordon Laboratory. 



276 



PEDIATRICS. 



HOME MODIFICATION.— GENERAL REMARKS ON ARTIFICIAL 
FOODS FOR INFANTS. 



HOME MODIFICATION. — I think that you will now agree with me 
that the importance of modifying milk with the most exact precision is self- 
evident if we expect to perfect a substitute food. Many persons are not 
near enough to milk-laboratories to have their infants' food prepared by this 
means. It is therefore necessary to provide for the preparation of the food 
for this class of cases in their homes. Under these circumstances I have, 
in conjunction with Mr. Gordon, made a recent study of the best means to 
accomplish this end, and I will describe them under the term of " Home 
Modification." I presuppose that absolute simplicity as to the materials 
used and such as can be obtained easily is necessary, and also that the 
method employed should be such as any physician can explain to a mother 
of ordinary intelligence. 

Fig. 68. 




sterilizer and thermometer. Stand for tubes. 



Sterilizer covered with cozy after removal from heat. 



Materials. — I have here to show you the materials which will make 
possible the home modification of milk for substitute feeding with an 
accuracy closely approximate, though not equal, to that of the Laboratory. 
All this apparatus and the same feeding-tubes that I have already de- 
scribed can be procured at the Laboratory for the original outfit. 

Home Sterilizer. — This is what is called the ^^ Home Sterilizer" (Fig. 
68). It is simply a tin can supported on legs so that it can be heated by a 



FEEDING. 277 

lamp, or, if preferable, the legs can be removed and the can placed on a 
stove. 

Thermometer. — It has a lid, to which is fitted a thermometer by which 
the degree of heat within the can is indicated. 

Tubes. — The tubes, varying in number according to the number of 
feedings which are required in twenty-four hours, are placed in this stand, 
which can be lowered into the sterilizer and be immersed in the water in 
the sterilizer, which is made to rise as high as the level of the milk in the 
tubes. 

Stoppers. — You see that the tubes are stoppled with cotton-wool, 
according to the usage at the Laboratory. 

Cozy. — I have also here another sterilizer, which has been covered with 
a thick cozy, through which the thermometer from the lid passes and indi- 
cates the degree of heat retained within the sterilizer after the flame has 
been removed. 

Graduate. — The other articles to be procured at the Laboratory are this 
250 c.c. {S^ ounces) glass graduate (Fig. 55, p. 251), divided, as you see, 
into half-drachms. 

Cotton-"W"ool. — Also a roll of aseptic non-absorbent cotton-wool. 

Milk-Sugar. — Also some milk-sugar. 

Sugar-Measure. — Also this sugar-measure, which holds 13.5 grammes 

(3f drachms). 

Fig. 69. 




Sugar-measure. 

This measure obviates the expense of having the milk-sugar put up in 
packages by the apothecary, and is sufficiently exact to regulate the sugar 
percentage in the mixtures which I shall speak of presently. It is well to 
remember, however, that a pound of milk-sugar contains 464 grammes 
(7000 grains), and that if you prefer to order the sugar in packages of 13.5 
grammes (3f drachms) directly from the apothecary, in place of using the 
measure, you can simply tell him to make thirty-five packages from the 
pound, and you can then direct a package of milk-sugar to be used instead 
of a measureful. 

Siphon. — Finally, they must have this glass siphon (Fig. 70), 0.6 cm. 
(J inch) calibre. The siphon can be used in any quart glass jars which the 
family happen to have. 

The siphon should be a glass tube one-quarter to one-half inch in 
diameter. It can be bent in a gas-flame. The end out of which the milk 
is to flow should be at least six inches longer than that which is to be in- 
serted in the jar. To operate the siphon, fill it with boiled water, close the 
longer end with the finger, invert the siphon, and place the shorter end in 
the milk. Then withdraw the finger, and the water, followed by the milk, 



278 



PEDIATRICS. 



Fig. 70. 



will run out of the long arm of the siphon. Do not use the mouth to start 
the flow of the milk through the siphon, under any circumstances. 

The mother is to be told that extreme precautions are to be taken to 
follow your directions to the minutest detail, or otherwise a uniformly cor- 
rect result will often be lost. You must ex- 
plain that the milk from a herd of cows is 
preferable to that of one cow, for many reasons, 
but especially because the elemental percentages 
are less likely to vary in the mixed milk of a 
herd than in that of the individual, and because 
the mixing lessens the deleterious effects on the 
milk arising from occasional disturbance of 
health in an individual member of the herd. 
The cows should be of a common breed, and 
such as give a moderately rich milk. The 
milk should be drawn with clean hands. The 
udders and teats of the cows should be cleansed, 
and the cows should be milked in as clean a 
place as possible. The milk should be thor- 
oughly strained. You will now have a milk 
fairly uniform in its elemental percentages and 
comparatively free from bacteria and foreign 
matter. The composition of this milk will 

Jar containing milk, cream, and usually correspond tO that which yOU SCC in 

siphon. C, cream; M, milk; S, si- .i . . i , / » i • Ar\ r»i o\ rm -n 

phon. this table (Analysis 40, page 218). Ihe milk 

is then set in a vessel containing ice and water 
with some salt, in the proportion of 5 grammes (1 teaspoonful) to 960 c.c. 
(1 quart) of water, and the vessel is set in some clean place. 

(Dr. Seibert, of New York, has recommended a system of filtering 
through a funnel containing aseptic cotton, and asserts that the bacteria are 
reduced in numbers one-half by this procedure. The fats, however, accord- 
ing to my experience in the use of this method, are also somewhat reduced, 
though not to any great degree. With the precautions taken, such as I have 
just stated for obtaining the milk-supply, the cotton filter will probably not 
be necessary, but it can be used, as Seibert intends it to be, where there are 
known to be much dirt and many bacteria in the milk. Dr. Seibert has 
had carefully prepared cotton disks and funnels made for filtering milk in 
this way.) 

You should always endeavor to prevent impurities from getting into the 
milk in preference to trying to eradicate them after they have begun to alter 
the normal composition of the milk. 

A clean, freshly boiled cotton cloth is next thrown over the uncovered 
quart jar. The mouth of the jar is kept open for about fifteen minutes, to 
dispose of the animal heat. The jar is then sealed tightly, as you would do 
for preserving, and is left in the ice-water for six hours, care being taken 




FEEDING. 279 

that the temperature of the water does not fall below 1.66° C. (35° F.). 
At the expiration of six hours you are to siphon out carefully from the 
bottom of the jar with this siphon (Fig. 70, page 278) 720 c.c. (24 ounces) 
of the milk into a clean glass vessel. 

You will now have your various materials ready for any combinations 
which you may wish to make in preparing the food for an especial infant. 
These materials are : the milk which you have siphoned from the jar, the 
cream containing ten per cent, of fat which remains in the jar, the sugar, 
either in packages as I have just described or in bulk, to be used when 
needed with the sugar-measure, some fresh lime water, and some clean 
drinking-water which has been boiled for five minutes. 

I have arranged in these tables (Tables 68 to 80) figures by means of 
which you can make the various combinations which you will be likely to 
need, and which correspond somewhat to the prescriptions that I have 
already shown you at the Laboratory : 

TABLE 68. 

Fat 0.25 

Sugar 4.00 

Proteids 0.25 

Lime water 5.00 

To obtain this combination with our materials, and to provide a suffi- 
cient quantity of food to last for twenty-four hours, you should give the 
following orders. 

Set enough milk to raise cream sufficient for the mixture required. For 
each twenty ounces, or part of twenty ounces, use the following formulae : 

Cream J ounce. 

Milk 1 ounce. 

Lime water 1 ounce. 

Water 17J ounces. 

20 ounces. 
Milk-sugar . 2 measures. 

The milk-sugar is to be thoroughly dissolved in the water of the mixture before the 
other materials are added. 

TABLE 69. 

Eat 1.00 Cream 2 ounces. 

Sugar 5.00 Milk 2 ounces. 

Proteids 0.75 Lime water 1 ounce. 

Lime water 5.00 Water 15 ounces,. 

20 ounces. 
Milk-sugar 2 measures. 



TABLE 70. 



Eat 2.00 

Sugar 5.00 

Proteids 75 

Lime water 5.00 



Cream , 4 ounces. 

Milk None. 

Lime water 1 ounce. 

Water 15 ounces. 

20 ounces. 
Milk-sugar 2 measures. 



280 



PEDIATBICS. 



TABLE 71. 



Fat 2.00 

Sugar 5.50 

Proteids 1.00 

Lime water 5.00 



Cream 4 ounces. 

Milk Ij ounces. 

Lime water 1 ounce. 

Water 13^ ounces. 

20 ounces. 
Milk-sugar 2^ measures. 



TABLE 72. 



Fat , . 2.50 

Sugar 6.00 

Proteids 1.00 

Lime water 5.00 



Cream 5 ounces. 

Milk None. 

Lime water 1 ounce. 

Water 14 ounces. 

20 ounces. 
Milk-sugar 2^ measures. 



TABLE 73. 



Fat 3.50 

Sugar 6.50 

Proteids 1.50 

Lime water 5.00 



Cream 7 ounces. 

Milk 1 ounce. 

Lime water 1 ounce. 

Water 11 ounces. 



20 ounces. 
Milk-sugar 2^ measures. 



TABLE 74. 



Fat ... , 4.00 

Sugar 7.00 

Proteids 1.50 

Lime water 5.00 



Cream 8 ounces. 

Milk None. 

Lime water 1 ounce. 

Water 11 ounces. 



20 ounces. 
Milk-sugar 2| measures. 



TABLE 75. 



Fat 4.00 

Sugar 7,00 

Proteids 2.00 

Lime water 5.00 



Cream 8 ounces. 

Milk 2^ ounces. 

Lime water 1 ounce. 

Water 8h ounces. 



20 ounces. 
Milk-sugar 2^ measures. 



TABLE 76. 



Fat 4.00 

Sugar 7.00 

Proteids 2.50 

Lime water 5.00 



Cream 8 ounces. 

Milk 5 ounces. 

Lime water 1 ounce. 

Water 6 ounces. 



20 ounces. 
Milk-sugar 2^ measures. 



TABLE 77. 



Fat 4.00 

Sugar 7.00 

Proteids 3.00 

Lime water 5.00 



Cream 8 ounces. 

Milk 7^ ounces. 

Lime water 1 ounce. 

Water S^ ounces. 

20 ounces. 
Milk-sugar 2 measures. 



FEEDING. 281 

TABLE 78. 

For weaning. 



Fat . . - 4.00 

Sugar 6.00 

Proteids 3.00 

Lime water 6.00 



Cream 8 ounces. 

Milk 7j ounces. 

Lime water 1 ounce. 

Water ^h ounces. 



20 ounces. 
Milk-sugar 1 measure. 



TABLE 79. 

For weaning. 



Fat 4.00 

Sugar 6.00 

Proteids 3.25 

Lime water 5.00 



Cream 8 ounces. 

Milk 8 ounces. 

Lime water 1 ounce. 

"Water 3 ounces. 



20 ounces. 
Milk-sugar ^ measure. 

TABLE 80. 

For weaning. 



Fat 4.00 

Sugar . 4. 60 

Proteids 3.50 



Cream . . = 8 ounces. 

Milk 12 ounces. 



20 ounces. 



After the various materials have been mixed, in the proportions which 
I have shown you in these tables, the mixture is prepared for the " home 
sterilizer/' The requisite amount of food for one feeding is poured into 
each of the tubes. They are stoppled with cotton-wool, care being taken 
to have a reasonably tight stopple in and a dry neck to the tubes. The 
tubes are then placed in the rack and lowered into the sterilizer, and the 
water in the sterilizer is adjusted to the level of the milk in the tubes. 
Heat, by means of a lamp or stove, is then applied to the sterilizer, which 
is watched, with the cover off, until the thermometer shows that the water- 
bath has reached a point of 77.2° C. (171° F.). The lamp is removed 
as soon as this temperature is reached, the cover put in place, and the cozy 
over it. The thermometer should mark a temperature of between 75° C. 
(167° F.) and 77.6° C. (170° F.) for thirty minutes, at the expiration of 
which time the tubes are to be removed from the sterilizer, and are to be 
kept in a cool place, preferably the ice-chest, until needed. 

OATS. — For the preparation of oat jelly the following method should 
be employed : 

120 grammes (4 ounces) of coarse oatmeal are allowed to soak in a quart 
of cold water for twelve hours. The mixture is then boiled down so as to 
make a pint, and is strained through a fine cloth while it is hot. 

When it cools, a jelly is formed, which is to be kept on ice until needed. 
Different proportions of this jelly can be used, but usually it is best to begin 
with equal parts of jelly and cow's milk. When needed, this mixture is 
warmed and a little salt is added. 

BARLEY. — Barley water is made by boiling 150 grammes (5 ounces) 



282 PEDIATRICS. 

of granulated barley in a quart of water until the volume is reduced to a 
pint, and then straining. 

If a barley jelly is to be made, 120 grammes (4 ounces) of barley flour 
are employed, and the same process is gone through with as for the prepa- 
ration of oat jelly. The resulting jelly is treated in the same way with 
milk as I have directed for oat jelly. 

"WHEAT. — Wheat can be prepared by the same method as that de- 
scribed for oats and barley. 

PEPTONIZED MILK. — For peptonizing milk, the following rules 
are the most practical and simple : 

In a clean glass jar containing 4 ounces of cold distilled or boiled water 
dissolve 1 gramme (15 grains) of bicarbonate of soda and 0.25 gramme (5 
grains) of pancreatine (extractum pancreatis), to which add 12 ounces of whole 
milk. Set the jar in a vessel of water at a temperature of 41.6° C. (107° F.) 
for from seven to ten minutes. Cool immediately, and keep on ice until used. 

To peptonize modified milk an amount of the powders should be used 
corresponding with the percentage of the proteids in the mixture, taking 
the standard of whole milk to be represented by four per cent, of the 
proteids. 

SWEET WHEY. — Sweet whey is best made by the following method : 

For each pint of whey needed take one quart of whole fresh milk, to 
which add 8 c.c. (2 drachms) of the essence of pepsin, or one square inch 
of rennet. When the proteids have been precipitated, break the curd 
finely with a fork, and pour off the fluid, straining it through two thick- 
nesses of boiled cheese-cloth. 

This removes such of the proteids as are coagulable by acids. 

Place this strained liquid in a clean porcelain pot, and raise the tempera- 
ture to the boiling-point by a stove or a lamp, but do not allow it to boil. 
Strain this hot liquid through a cloth as before. 

This removes the proteids coagulable by heat. 

Cool the resulting fluid slowly to a temperature of 10° C. (50° F.), and 
keep on ice until needed. 

ARTIFICIAL FOODS FOR INFANTS.— It would seem hardly 
necessary to suggest that the proper authority for establishing rules for sub- 
stitute feeding should emanate from the medical profession, and not from 
non-medical capitalists. Yet, when we study the history of artificial 
feeding as it is represented all over the world, the position which the family 
physician occupies, in comparison with that of the venders of the number- 
less patent and proprietary artificial foods administered by the nurses, is a 
humiliating one, and should no longer be tolerated. 

If we are abreast of the times, if we but recognize and do justice to the 
work which has lately been done by our own profession, we surely will 
not hesitate to relegate to oblivion the statements of the food proprietors, 
which on box and can, on bottle and printed circular, attempt to stem the 
slow but inevitably progressing wave of scientific investigation. 



FEEDING. 283 

It may be well to bear in mind that the attempts which in the past have 
been made to manufacture cheap foods have been markedly failures. We 
must first, regardless of expense, learn to produce by modification a per- 
fected substitute food, and not endanger the success of our undertaking by 
allowing the mercantile side of the question to cripple us in the use of costly 
methods, which, however, we know to be the best. We should, in fact, 
remember that the human milk, which we are endeavoring to copy, far 
from being a cheap product, is a very expensive one. 

My own opinion in regard to patent foods, as a whole, is that they must 
necessarily be unreliable. They are thrown on a market where the compe- 
tition is extreme, and when once they have been advertised into public 
notice I cannot but feel that irregularities and changes — slight, perhaps, in 
the eyes of the makers — may unintentionally creep in and carry their com- 
position still further from that of the standard, human milk. 

Analyses show that there is a lack of uniformity in these foods from 
year to year, and that original claims are apparently forgotten or allowed to 
give way to cheaper production. In fact, as my experience in the feeding 
of infants increases, and as I examine year by year the effects of the different 
foods on infants, I am strongly impressed with the belief that with our pres- 
ent physiological, chemical, and clinical knowledge all the patent foods are 
entirely unnecessary. The claims made for them are not supported by in- 
telligent and unprejudiced investigation. Those who manufacture them are 
not in a position to judge correctly concerning them. The merit at times 
of their apparent success does not belong to them, but to accompanying 
circumstances. They do great harm by impressing upon the public the 
false idea that a cheap, easily prepared food is for the good of the infant and 
is better than anything which can be procured elsewhere. They vary too 
greatly in their analyses to keep even within the acknowledged varying 
limits of human milk. It is therefore high time for physicians to ap- 
preciate exactly how inefficient in themselves and how misleading in their 
claims are these artificial foods, and also in what a false position, as the 
protector of and adviser to the public, our profession is placed whenever it 
lends itself to even a toleration of their use. I speak of them here simply 
because there is no doubt that they are kept in the market by the physi- 
cian rather than by the manufacturer. The latter is only doing what any 
capitalist interested in a business venture would do. The former, it seems 
to me, is, perhaps unintentionally, aiding the business interests of others at 
the expense of his own future reputation as a scientist. It makes little dif- 
ference to physicians as to what is claimed for these foods when they are 
placed in the market. It makes a great difference what the mixture con- 
tains when given by the mother to the infant according to the directions on 
the label. For instance, a food may show by its published and certified 
analysis a fair percentage of fat or sugar, and yet this same food when 
diluted for the infant's feeding may have these constituents reduced far 
below the reasonable limits of nutrition. 



284 PEDIATRICS. 



IvKCTTURK XI. 

THE SECOND AND THIRD NUTRITIVE PERIODS. 

SECOND NUTRITIVE PERIOD. — During the eleventh and twelfth 
months of life the amylolytic function of the infant has become almost fully 
developed. In accordance with the rule regarding the use of the different 
functions, which I have already spoken of, — namely, that a function should 
not be taxed before it is developed, but that when its development is almost 
completed it should be brought into use, — we should in the latter part of the 
first year begin to use that function of the digestive tract by means of which 
the amylaceous elements of the food are converted into sugar. 

In speaking of weaning I have already explained to you the value of 
using preparations of oats or barley mixed with milk. I have also shown 
you how to reduce gradually the percentage of sugar in the modified milk 
which is being given at the tenth and eleventh months and at the same 
time to increase the percentage of the proteids. The reason for changing 
the relative percentages of these elements is that the power to digest proteids 
has much increased during the latter part of the first year. The capacity 
for digesting a high percentage of sugar is just as great at this period as at 
an earlier one, but the amount of sugar, given directly as such, which is re- 
quired in the later is not so great proportionately as in the earlier period. 
A large portion of the sugar which is needed for nutrition in this later 
period is intended to be introduced into the economy by means of a new 
element in the food, — starch. A certain amount of sugar is, as before, 
directly introduced into the gastro-enteric tract from the milk-sugar of the 
milk, and the starch when converted into sugar supplies the remaining por- 
tion of sugar needed for nutrition. In a normal infant with normal digestive 
functions a considerable percentage of starch can be digested and absorbed 
with benefit in the eleventh and twelfth months. 

I am therefore in the habit of giving preparations of oats or barley 
when I have decided that starch should be introduced into an infant's food. 
There is a larger percentage of starch in oats than in barley. It is also 
more nutritious in every respect, as it contains a considerable percentage of 
fat. The starch in oats takes a somewhat longer time to be converted into 
sugar than does that of barley, so that in the case of an infant whose 
amylolytic function is not fully developed or is somewhat weak, prepara- 
tions of barley will be better to begin with, because they do not intro- 
duce so high a percentage of starch into the food, and also because the 
starch will be more readily converted into sugar. Preparations of oats 
seem to be the best form of food to be added to the modified milk when the 



FEEDING. 285 

infant has reached a period at which it needs a change in the character of 
its food. 

When the infant has reached the fifth or sixth month of its life it nor- 
mally should be able to digest four per cent, of fat in its food. This percent- 
age of fat corresponds, as I have already shown you, to that which exists 
in average cow^s milk. It is natural to suppose that at the eleventh and 
twelfth months a still further increase in the amount of fat which is pro- 
vided in the infant's food is required, as well as the new element, starch. 
This fat is supplied, as I have already told you, in considerable quantity 
from the oats. 

We have therefore, in preparations of oats, both for purposes of weaning 
and for establishing a new regimen of diet for the infant, a food which in 
combination with cow's milk satisfies completely the demands which the 
digestive functions at this period are making for a perfect nutriment. 

The second nutritive period may be reckoned to last from the twelfth to 
the twenty-eighth or thirtieth month of life. That is about the second half 
of the period which we are in the habit of calling mfancy. It also in- 
cludes the time when the last four teeth of the first set appear. In this 
second nutritive period the element of variety in the food becomes important. 
It is undoubtedly important that the actual nutritive values of the food which 
it is best to give to infants in this period be considered, but it is much more 
important that special attention be paid to its variety. Foods should be 
given which while containing a fair percentage of nutritive elements yet 
differ in the combination of these elements to such a degree that they fulfil 
the requirements of this period of life. It is best to increase gradually the 
variety of articles of diet from the twelfth to the twentieth month, always 
adapting the food to the especial infant. Thus, some infants may be able 
to digest and assimilate proportionately large quantities of starch ; others 
may both need and digest larger proportions of the proteids or of sugar than 
the infants first spoken of. 

Between the twelfth and thirteenth months I am in the habit of giving 
the infant five meals during the day. At this time it is well to accustom 
it to take its food from a spoon, and as soon as possible to omit feeding from 
the bottle. The five meals should be arranged in the following manner : 

For breakfast, bread and cow's milk, slightly warmed. 

For lunch, equal parts of oat jelly and cow's milk, warmed, with a 
little salt added according to the infant's taste. 

This meal of oat jelly should be repeated in the middle of the after- 
noon. 

In the middle of the day, broth of some kind, either chicken or mutton, 
carefully prepared so as to be free from fat on its surface, can be given with 
some bread. 

The fifth meal should be given in the latter part of the afternoon, and 
should consist of bread and milk. 

In some cases it is impossible to make infants swallow bread for a 



286 PEDIATRICS. 

long period after the usual time of twelve to thirteen months. At times it 
is not until they are two and one-half to three years old that they can be 
induced to take bread. In these cases we must feed them according to our 
judgment of the individual case. 

When the infant is fourteen to fifteen months old, some thoroughly 
boiled rice can be added to the broth in the middle of the day, and if it 
digests this well it can also have bread given with this meal. 

When the infant is sixteen months old, it can have a small amount of 
butter on its bread. When it is seventeen to eighteen months old, it can 
have a thoroughly baked white potato, mixed with butter and salt, added 
to its mid-day meal of broth. When it is nineteen to twenty months old, 
eggs can become part of its diet. 

There are not many fruits which should be given to the infant in its 
second year. A baked apple can be given at the evening meal when the 
infant is fourteen to fifteen months old ; or, for variety, the apple can be 
made into a simple sauce, never, however, having the sauce made with 
much sugar. When peaches are in season, a ripe peach can often be given 
with benefit, especially if the infant is inclined to be constipated. Other 
fruits should be avoided, as they are not necessary for the infant's nutrition 
and at times produce serious trouble. 

This is the diet w^hich is sufficient for the infant during the second nutri- 
tive period. It is important for the subsequent integrity of the infant's 
digestion and general nutrition that the parents should insist that no other 
articles of food be employed, except such as are similar to those which I 
have spoken of, — namely, the cereals in a variety of forms, according to the 
taste, judgment, and knowledge of cooking which exists in the special 
household. For instance, preparations of wheat and barley cooked in 
various forms may be given in place of oatmeal. Bread also in different 
forms may be given. The crust of French bread is easily digested, and is 
supposed to have less starch in proportion to its gluten than the usual home- 
made bread. It is well to begin with some form of bread of this kind 
when we are getting the infant accustomed to take starch in the form of 
bread. If it is constipated, Graham bread and preparations of rye will also 
be found useful. Fresh bread should never be given, and bread one day 
old is the preferable form which should be provided. 

The infant should never be given cake or candy even to taste. I think 
that it is necessary to state this very decidedly, because it is an erroneous 
view which is held by most mothers that it can do no harm to give occasion- 
ally to an infant in its second year of life, or to a yoimg child, a little candy 
or a little cake. This may be true so far as the immediate effect these articles 
may have on the digestion is concerned, but it is of far more importance that 
the infant should not have its taste perverted from those articles of diet 
which are best for its nutrition. These new articles appeal more strongly 
to its sense of taste, and allow it to know that there is something which 
tastes more agreeable than the food which it is accustomed to have. When 



FEEDING. 287 

an infant has acquired a taste for cake or candy, it will cease to enjoy the 
food by which its development will be best perfected. It is, in fact, kinder 
to the infant never to allow it to taste cake or candy. When these articles 
are withheld, it will continue to have a healthy appetite and taste for neces- 
sary and proper articles of food. 

I am so often asked by mothers what is the best method of preparing 
simple broths for their infants that perhaps it may be well for you to know 
how these broths should be made. 

CHICKEN BROTH. — A fowl weighing about five pounds should be 
boiled for about twelve hours. The fluid should be strained while hot 
through a fine sieve. It should then be allowed to cool in an earthen jar 
for about twelve hours in the ice-chest. The resulting jelly can be used in 
full strength or diluted with water. When the jelly has been thoroughly 
cooled, the fat can be either partially or entirely removed from the top. 

MUTTON BROTH.— A shoulder of lamb, when it can be obtained, 
— otherwise of mutton, — weighing from five to seven pounds, is treated in 
the same way as is the fowl for the preparation of chicken broth. 

THE THIRD NUTRITIVE PERIOD.— The third nutritive period 
I have arbitrarily made to begin at about the thirtieth month of life. 

At this time it will be well to begin to accustom the child's digestive 
functions to a still greater variety of food. In summer the more easily 
digestible vegetables, such as squash, young peas, and young beans, can be 
given. The variety of fruits can also be increased at this period, but they 
should be cooked. The principal change which is to be made in the diet to 
which the infant has been accustomed is a very decided increase in the pro- 
portion of the proteid element of its food. This is accomplished by means 
of giving the child meat. The quantity of meat which should be given 
towards the end of the third year should be small at first, and should be 
given at intervals of a day or two. Meat as a regular article of diet for 
each day is not, as a rule, required until the child is between three and four 
years old. The kinds of meat which should be given in this early period 
of childhood are chicken, mutton-chop, roast beef, and beefsteak. These 
meats should be cut into small pieces, and a little salt added according to 
the child's taste. It is well, during the latter part of the third year and the 
first half of the fourth year, to give the child an egg on one da}^ and meat 
on the next. 

When the child has reached the age of five or six years, we should allow 
it to have a somewhat more varied diet, but during the whole period of 
childhood up to the age of puberty the closest attention should be given 
to the regulation of the kind and the amount of food to be given to the 
child, and any deviations from the rules which I have just laid down are to 
be deprecated. 



DIVISION V. 

PREMATURE INFANTS 



IvEcture: XII. 

I SHALL next speak of that class of infants which is designated as pre- 
mature, because they are born prior to the usual two hundred and eighty 
days which represent the normal duration of intra-uterine life. I describe 
this class of cases directly after what I have just told you about infant feed- 
ing not only because it is essentially the proper management of the food 
which preserves the lives of these infants, but because I consider that the 
best way to feed premature infants is by means of food carefully prepared at 
milk-laboratories. This method of feeding premature infants is far superior 
to even breast-feeding, and, in my opinion, the use of milk -laboratories in 
these cases will result in a decided reduction in their mortality. 

Very few cases are reported, and none of them appear to be absolutely 
authentic, where an infant has survived which was born much before the 
twenty-seventh or twenty-eighth week of intra-uterine life. The premature 
infant in its intra-uterine development is unprepared to meet the conditions 
of extra-uterine life, and often dies within a few days, and usually within 
a few hours. 

A sufficient number of careful investigations regarding the characteristic 
appearances and the development of the foetus during the last four months 
of intra-uterine life has not yet been made and recorded to enable us to 
state definitely what age the infant represents when it is born. The few 
facts which we possess concerning this subject must, however, be made use 
of, and, though not absolutely correct, are sufficiently so to be of great value 
to us in our management of these cases. One reason for the difficulty which 
arises in every case in determining the age of the foetus is that the condi- 
tions which influence its growth during intra-uterine life are very varied. 
The health of the mother and her hygienic surroundings, together with the 
influence of heredity on the size of her offspring, present good reasons for 
decided variations in the growth of the foetus in different cases at the same 
period of intra-uterine life. 

If the infant is living when it is born, we should at once carry out the 
288 



PREMATURE INFANTS. 289 

rules for preserving its life which have proved to be best in the case of any- 
infant born prematurely. These rules should be insisted on even if the 
infant has been born at a much earlier stage of development than is, accord- 
ing to our present ideas, compatible with its viability. This is necessary, 
because so many errors in our calculation as to when the impregnation took 
place are liable to arise, and also because a foetus may have arrived at a 
period of intra-uterine development which is perfectly compatible with life, 
and yet from its small weight and general characteristics have the appear- 
ance of one whose development is incompatible. Whatever advances we 
may make in the future in preserving the lives of premature infants born 
at an earlier date than is supposed to be compatible with life, — namely, from 
the twenty-fourth to the twenty-eighth week, — it would hardly be practical 
at this time to discuss the treatment of infants born before the twenty- fourth 
week. 

TWENTY-FOUR WEEKS.— A foetus born at about the twenty- 
fourth week of intra-uterine life usually breathes feebly, and dies in the 
course of a few hours, apparently from an inability to accommodate itself 
to conditions for which it is not prepared. At this stage of development 
it may still have fine hair (lanugo) over the whole of its body, but it is 
often the case that this hair, commonly found from the sixteenth to the 
twentieth week, has disappeared. At this age it still has very little deposi- 
tion of fat in the subcutaneous cellular tissue, and it has a decidedly emaci- 
ated appearance. In other respects, except its size, it does not differ very 
much in its appearance from the foetus of some weeks' later development. 
Its eyelids have separated, though it is so feeble that, as a rule, it cannot 
open and shut them. 

The estimation of the length of the foetus is difficult to make, and, on 
the whole, unsatisfactory and inexact. These measurements, in all proba- 
bility, differ very much when made by different investigators, owing, as 
Minot has pointed out, to the many changes in the curvature of the longi- 
tudinal axis of the human embryo, which make it impracticable to employ 
any one system of measurement in obtaining comparable results for all ages. 
Hecker's figures, however, are probably as reliable as any we know of. 
According to this author, at about the twenty-fourth week the foetus meas- 
ures 28 to 34 cm. (11 J to 13 J inches). Its weight, according to Lusk, is 
about 690 grammes (23 ounces). 

TWENTY-EIGHT WEEKS.— By the time the foetus has reached the 
twenty-eighth to the twenty-ninth week of intra-uterine existence its con- 
dition, so far as its development is concerned, is such that there is no neces- 
sary contra-indication to its living if it happens to be born at this time. 
It has been stated that an infant born prematurely at the twenty -eighth 
week is more likely to live than one which is born at the thirty-second week 
of intra-uterine life, and that this has been proved by statistics. If true, 
the reason for this, I believe, is because much greater care is taken of the 
former than of the latter. It is reasonable to believe that an earlier stage 

19 



290 PEDIATRICS. 

of intra-uterine development is less likely to insure continuance of life after 
premature birth than a later stage, provided the same precautions are taken 
in each case. 

Hecker's and Lusk's figures, in a general way, state that when the foetus 
is born at about the twenty-eighth to the twenty-ninth week it measures from 
35 to 38 cm. (about 13f to 15 inches) and weighs about 1170 grammes 
(39 ounces). The skin is still wrinkled, is of a dull red color, is covered 
with vernix caseosa, and there is very little deposition of subcutaneous fat. 
The infant can move its limbs slightly, cries feebly, and often dies in a few 
hours or days. Yet it is this class of prematurely born infants whose lives 
I expect to see preserved in the future, when all the precautions which I 
am about to describe against external and dangerous influences have been 
taken and improved apparatus has been employed. 

THIRTY-T"WO WEEKS. — Again, using Hecker's and Lusk's figures 
for the thirty-second, thirty-sixth, and thirty-eighth weeks, at about the 
thirty-second week of intra-uterine life the foetus measures from 39 to 41 
cm. (about 15 J to 16 J inches) and weighs about 1560 grammes (52 ounces). 
The hair of the head by this time has increased in thickness, and the lanugo^ 
which in many cases is pronounced from the twenty-eighth to the thirty- 
second week, has either begun to disappear or has entirely disappeared from 
the face. The nails, which between the twenty-eighth and thirty-second 
weeks are often not well developed, now present a normal appearance, though 
they frequently do not quite reach the tips of the fingers. At this age, 
also, in boys, it is often possible to feel the testicle in the scrotum. There is 
usually, also, at this age, in a healthy foetus, considerable deposition of sub- 
cutaneous fat, and the senile aspect of the earlier periods of intra-uterine life 
is much lessened. 

THIRTY-SIX WEEKS.— At about the thirty-sixth week the lengtk 
of the foetus is from 42 to 44 cm. (about 16f to 17 J inches) and its weight 
is about 1920 grammes (64 ounces). The lanugo has usually at this period 
disappeared, and the infant, although less energetic than at full term, is 
decidedly stronger than in the previous periods which I have mentioned. 
It sleeps a great deal, and is still in a condition to die easily unless carefully 
looked after. 

THIRTY-EIGHT WEEKS.— At about the thirty-eighth week of intra- 
uterine life the infant measures about 45 to 47 cm. (about 17f to 18f inches) 
and weighs about 2310 grammes (77 ounces). 

WEIGHT. — It is important to remember that the weight of premature 
infants of the same age varies at birth, just as we have seen that it does in 
the case of infants born at term. 

In treating these cases, observance of their weight is of the greatest 
importance, and until we have obtained a regular progressive daily increase 
in their weight we are never sure that they are thriving sufficiently to live. 
The daily gain which the premature infant should make has not yet been 
determined, but it is much less than is expected when an infant is born at 



PEEMATUEE INFANTS. 291 

full term, and may be stated to be about 10 to 20 grammes {^ to f ounce). 
Any decided loss in weight, such as 30 to 40 grammes (1 to 1 J ounces), 
beyond what would occur from natural causes, should make us look upon 
the infant as being in a critical condition and impress upon us the impor- 
tance of taking active measures to prevent further loss. This loss in weight 
must, as it is relatively so small, be carefully adjusted to the loss which 
naturally occurs from the fgecal discharges. Thus, the total amount of loss 
in weight from the fsecal discharges may amount in these premature infants 
to from 30 to 60 grammes (1 to 2 ounces) for each faecal discharge, and this 
may entail a considerable loss of the infant's weight in the twenty-four 
hours beyond that occasioned by defective nutrition. 

I have here to show you an infant (Case 102) prematurely born at about 
the twenty-eighth week of intra-uterine life. 

Case 102. 





\ 



Infant premature at seventh month. Birth-weight, 1740 grammes ; present weight, 1540 grammes ; present 

age, 10 days. 

Its weight at birth was 1740 grammes (about 3f pounds). It is now ten days old and 
has lost about 240 grammes (about ^ pound) . You see that it is in a very somnolent con- 
dition, that it has very little hair on its head, and very little subcutaneous fat. You will 
also notice the senile expression of its face, that there is no appearance of lanugo, and that 
the nails are well formed. The small size of the infant will be still more appreciated if you 
compare it with the hand of the nurse, which, for comparison, is placed beside it. 

There have been so few observations recorded of the development of the 
various parts of the foetus in the later months of intra-uterine life that I 
am not prepared to describe systematically the development of the prema- 
ture infant as I have already done that of the infant at term (Lecture III., 
page 54). There are, however, some facts which I have observed and others 
which have been recorded. 

HEAD, THORAX, AND ABDOMEN.— Looking at this infant (Case 
102) critically, we notice that all those anatomical conditions which I have 
emphasized in my description of the infant at term as being especially 
prominent are still more marked in the premature infant. Thus, you will 
notice how large the head is in comparison with the thorax, and how very 
large, in proportion, is the abdomen. The abdomen is in almost every case 
much distended in premature infants, owing to the large proportionate size 
of the liver. This distention of the abdomen lasts for many weeks, and 



292 



PEDIATRICS. 




•♦», 



even months, and its gradual return to the normal size and appearance 
is one of the signs that the infant is doing well and is gradually acquiring 

the normal anatomical development 
Fig. 71. of the infant born at term. 

SKIN. — The various changes in 
the color of the skin, which I have 
already described as represented by 
erythema neonatorum and icterus 
neonatorum, I have noticed to occur 
in the premature infant as they do in 
the infant at term. 

SWEAT - GLANDS.— I have 
told you that the function of the 
sweat-glands is, as a rule, not de- 
veloped at birth, and that we do not 
expect the infant in the early weeks 
of life to perspire. I have also told 
you that there is a great variation as 
to the time of the development of the function of the sweat-glands. In an 

Fig. 72. 




TraciBjs of foetal feet (natural size), seven months 
old. 




Legs and feet (natural size) of infant premature at seven months. Left foot dissected and showing 
internal arch. Partially dissected metatarso-phalangeal joint of great toe in shadow. Inferior edge of 
scaphoid shows as a shaded line. 

infant premature at seven and one-half months I have noticed free perspi- 
ration take place after it had been born one week. 



PREMATURE INFANTS. 293 

FEET. — I have already told you how few observations have been made 
on the development of the various parts of the foetus in the later months of 
intra-uterine life, and I think all facts determined at this period of existence 
should be recorded. I therefore consider Dane's observations on the instep 
of a seven months' foetus (Case 103) born alive to be of value in connection 
with what I have already said about the feet of infants born at term (Lec- 
ture II., p. 50). These tracings (Fig. 71) represent this premature infant's 
feet, and you see how admirably the presence of the instep is shown. 

The infant died a few hours after birth, and I have here to show you (Fig. 72) its feet 
and lower legs. The skin of the right leg is badly wrinkled by the alcohol in which it was 
preserved. It looks strikingly like the foot as it appears in adults, and its arch stands out 
plainly, unmasked by any pads of fat. The left foot has been dissected down to the liga- 
ments. The arch made by the os calcis, cuboid, and fifth metatarsal bones represents the 
lower edge of the cut. On the inner border of the foot the metatarso-phalangeal joint of 
the great toe is seen partially dissected. Behind this the enlargement at the tarso-metatarsal 
joint forms a considerable bulging. Behind and above the latter the inferior edge of the 
scaphoid shows as a shaded line. 

From these specimens and from the tracings we see that the foot at 
seven months closely approaches in external appearances the well-developed 
foot of the adult, and that when the infant was supported with its feet on 
smoked paper it left an excellent impression. The dissection also shows a 
remarkably well constructed bony framework. 

GASTRIC CAPACITY. — As the question of the proper amount of 
food to be given to a premature infant is of the utmost importance, it is 
well to know about what the average gastric capacity of the foetus is during 
the later months of intra-uterine life. No series of complete and reliable 
observations on this point have been made, that I know of, and the rules by 
which we are guided must for the present be very general ones. The less 
the weight of the infant, the less, in many cases, is the gastric capacity. I 
have here to show you some foetal stomachs. 

The first stomach (Fig. 73) is that of a foetus about four and one-half months old, and 
is interesting merely as showing the relatively advanced development of the lesser and 



Fig. 73. 





Foetal stomach (natural Foetal Stomach (natural size), seven and one-half months 

size), four and one-half old. Weight of foetus, 1920 grammes. Gastric capacity, 

months old. 18c.c. 

greater curvatures at this age, as well as the rapid growth which takes place between the 
fourth and the seventh month. 



294 



PEDIATRICS. 



The next stomach (Fig. 74, p. 293) was taken from an infant born prematurely at 
about the twenty-ninth to the thirtieth week. It is of a rather peculiar shape, corre- 
sponding to that which I have described to you in a previous lecture (Lecture TV. , Fig. 
29, p. 89). The weight of this foetus w^as 1920 grammes (about 4 pounds). Its gastric 
capacity was 18 c.c. (about 4 J drachms). 

This next stomach (Fig. 75) was taken from a foetus at about the thirty-second week, 
which died in forty-five minutes from the time of its birth. The gastric capacity was 22 
c.c. (5^ drachms). The weight of this infant was 1230 grammes (2 pounds 9 ounces). 

Fig. 75. 




Foetal stomach (natural size), eight months old. Weight of foetus, 1230 grammes. Gastric capacity, 22 c.c. 



The next stomach (Fig. 76) was taken from a foetus born at about the thirty-second 
week of intra-uterine life, and weighing 1440 grammes (about 3 pounds). Its gastric 
capacity was 8 c.c. (about 2 drachms). 

Fig. 76. 




Foetal stomach (natural size), eight months old. Weight of foetus, 1440 grammes. Gastric capacity, 8 c.c. 

INTESTINAL CONTBNTS.—The meconium in prematm-e infants 
presents the same appearance as is seen in infants at term. When the food 
is properly regulated, the fsecal discharges assume the consistency and 
color which are seen in those of infants who have been born at term. This 
color m its usual varieties is well represented in this plate (Plate III., 6, 
7, S, 9, facing p. 112). 

AMYLOLYTIC FUNCTION.— The amylol}^ic function of the infant 
at term is so slightly developed that we may safely assume that it should 
not be depended upon for the digestion of starch in the premature infant 
under any circumstances. 



PREMATURE IXFANTS. 295 

SUGAR. — ^Although we must assume that the function of absorbing 
sugar is not developed to the same extent in the premature infant as in the 
infant at term, yet, in all probability, it is more highly developed than the 
other functions of digestion. Sugar is needed to keep up the animal heat 
of the premature infant, which is so very much more readily lessened than 
in the infant at term. Sugar, therefore, is an important element in the 
premature infant's food, but should be given at first in a much lower 
percentage than later, when the equilibrium of the gastro-enteric tract has 
been acquired. 

FAT AND PROTEID DIGESTION.— The flmction of digesting fat 
and proteids is in a much more undeveloped condition in the prematm-e 
infant than in the infant born at term, and should, therefore, not be de- 
pended upon to the same degree as can safely be done in arranging the food 
for the older infant. Much smaller percentages of these elements should 
be given to the premature infant than to the infant at term, both for pur- 
poses of digestion and of absorption, for, in all probability, the power of 
absorption of the gastro-enteric tract in premature infants is in a very im- 
developed condition. 

KIDNEY. — We should expect, from the lack of development of the 
kidney in premature infants, to find a considerable deposit of uric acid, such 
as I have described as appearing in the early days of life in infants at term 
(Lecture IV., page 111, Plate III., 1). This is, in fact, the case, and the 
appearance of uric acid on the napkins of premature infants is, therefore, 
not necessarily to be looked upon as denoting an abnormal condition. It 
should, however, be carefully watched, for where it becomes excessive it is 
an indication that the infant's food has not been properly adjusted to its 
digestive powers and that the infant may soon begin to fail. 

CIRCULATION. — The heart in premature infants has not yet arrived 
at the complete stage of development needed to render it a reliable central 
force which can fulfil the demands that will be made on it in the external 
world to sustain the equilibrium of the circulation. Therefore as little 
work as is possible should be thrown upon the heart, and the infant 
should be kept quiet, and not be carried about, as is customary with 
infants born at term. 

In a number of cases which I have carefully examined I have failed 
to detect a cardiac murmur, which leads me to think that the foramen 
ovale closes soon after birth in the same manner as it does in the infant 
at term. 

ANIMAL HEAT. — The animal heat of the premature infant is much 
more easily reduced, and is even more important to its vitality, than it is in 
the infant at term. Following the rule that the smaller the size of the 
human being the greater proportionately is the entire surface, and, therefore, 
the greater the opportunity for lowering its temperature, an atmosj)here 
which is suitable for the infant at term is too cold for the premature 
infant. 



296 PEDIATRICS. 

Premature infants should be thoroughly protected from changes of tem- 
perature of the atmosphere in which they live, and this temperature should 
be raised to a point which will correspond in some degree to that of intra- 
uterine life. 

AIR. — Just as a necessity exists for the premature infant to live for 
some weeks in an atmosphere where the air approaches in its temperature 
the warmth which exists in intra-uterine life, so is it almost to the same 
degree important that the air which it breathes should be free from dust and 
micro-organisms. The lung is in a very undeveloped condition, and although 
it may be sufficiently developed to carry on the function required of it in 
extra-uterine life, yet all its tissues are exceedingly sensitive, as are those of 
the nose and naso-pharynx through which the air must be introduced to the 
lungs. The air of the ordinary room where infants live when they are born 
necessarily contains many impurities, both irritating and morbid. This 
irritation of the respiratory passages may of itself be sufficient to reduce the 
vitality of the infant beyond the limits of life. 

TOUCH. — Premature infants have to be carefully handled, as they die 
easily from influences which would have little or no effect upon the infant 
born at term. In intra-uterine life they are floating in a fluid which prac- 
tically prevents what in the external world corresponds to handling. While 
they are living in the amniotic fluid they are almost completely protected 
from the influence of touch, which necessarily affects them as soon as they 
are born. Touch, then, is an important element, to be as much as possible 
avoided when the premature infant is born, as it has a decided tendency to 
lower the vitality. 

An instance of the care which is needed to preserve the lives of these 
infants came to my notice in the case of an infant (Case 104) premature at 
eight months which was in my service at the City Hospital. 

During the first week or ten days of its life this infant was in charge of an unusually- 
careful and experienced nurse, who appreciated the risk of handling it. It was gaining in 
weight and was doing well ; but unfortunately another nurse was substituted who did not 
understand this class of infants so well. She allowed the patients in the ward to handle 
the infant, to talk to it, and to surround it with various similar deleterious influences. Eor 
a few days it lost in weight, and then it suddenly died. There is no doubt that it was un- 
able to withstand the amount of handling which would have done no harm to an older 
infant. 

LIGHT. — The premature infant should live in comparative darkness 
during the early weeks of its life. Light is not requisite for the develop- 
ment of the infant in the earlier stages of its existence, and too much light 
will impair its vitality. It is important to adapt the light to the stage 
of its development, and gradually to accustom it to more light as it grows 
older. 

SOUND. — In the normal intra-uterine conditions the infant is very 
slightly exposed to sound, and all its fnnctions are adapted to silence rather 
than to the many noises which unavoidably surround it in tlie external 



PREMATURE INFANTS. 297 

world. We should therefore arrange that from the minute it is born it is 
protected from noise. 

PULSE, TEMPERATURE, AND RESPIRATION.— I have not any 
very exact records of the average pulse, temperature, and respiration found 
in premature infants. These infants seem to present rather irregular types of 
temperature and pulse, as well as of respiration. They have to be so care- 
fully handled that observations as to these physical signs must be made with 
great caution. The main point in regard to these three conditions of the 
premature infant is that they are all represented by irregularity. The tem- 
perature of the premature infant, when it has once begun to gain in weight 
and to thrive, is usually a little above the normal temperature of the infant 
at term. Before it has begun to gain in weight and when its vitality is 
much depressed, the temperature, as w^ould naturally be expected, is rather 
below the normal standard ; and we should watch this sign with the greatest 
solicitude, as a decided and continuous depression is often indicative of 
death. 

The jpulse is difficult to take in the premature infant, and, as a rule, is 
somewhat quicker than in the infant at term. 

The respirations J irregular in the infant at term, are still more irregular 
in the premature infant, at times being rapid for a few seconds, and then 
becoming almost imperceptible for some minutes. 

This infant whicli I have had brought here to show you (Case 105) was prematurely 
born at the thirty-second week, and illustrates the fact that a premature infant, if its 
weight is not extremely small and if its development is somewhat above the average ex- 
pected for its age, can live and thrive without all the precautions being taken for its 
preservation which I have already spoken of. These cases, however, merely emphasize the 
fact that if we are guided by them in our treatment of premature infants in general, we 
shall make many fatal mistakes and far fewer lives will be saved. 

This infant weighed at birth 2954 grammes (about 6 J pounds). This would indicate 
that its chances for living were good, the other conditions of its development being normal, 
as you will understand by referring to this table (Table 2, p. 49) of the relation of weight 
to vitality. You see that the weight of this infant is between 2500 and 3000 grammes, 
showing that the vitality has risen above what is designated as low ; in fact, it is within 49 
grammes (about If ounces) of the 3000 grammes which represent a fair vitality. The in- 
fant was kept in a room where the temperature was 23.8° C. (75° F.). The air which was 
around its bed, which was in a basket, was heated to about 29.4° C. (85° F.). The infant 
was wrapped in fresh absorbent cotton. During the first twenty-four hours one teaspoonful 
of food was given every hour. After that time it was fed every hour during the day, and 
every two hours during the night. On the third day the mother had a sufficient supply of 
breast-milk, which flowed easily. The infant was therefore fed with the breast-milk from 
a spoon for a week, was then put directly to the breast, and continued to nurse until the 
end of the third week, when, as its mother's milk failed, it again had to be placed upon a 
carefully regulated substitute food. 

There is nothing else especially interesting to record either in its history or in its 
physical condition, except that it had a small umbilical hernia, which did not cause any 
discomfort, and which closed at the end of the third month. 

With this attention to its warmth and food it throve as any infant at term would have 
done, and has since been well and strong. 

Here is a table (Table 81) which represents its weight for sixty-one days, and here 
is the record (Chart 5) of its temperature and pulse during the first three weeks of its life. 



298 



PEDIATRICS. 



TABLE 81. 



Weight for Sixty-One Days of Infant Premature at Thirty-Two Weeks. 



Day of Life. 
Birth-weight 
Third . . 
Sixth . . 
Ninth . . 
Thirteenth 
Sixteenth 
Twentieth 
Twenty-third . 
Twenty-seventh 
Thirtieth . . 
Thirty-third . 
Thirty-seventh 
Forty-first . . 
Forty-fourth , 
Forty-eighth . 
Fifty-first . . 
Fifty-fifth . . 
Fifty-eighth . 
Sixty-first . . 



Grammes. (Pounds. Oz.) 



2964 
2724 
2814 
2964 
3178 
3388 
3598 
3812 
4116 
4236 
4476 
4600 
4840 
4900 
4994 
5084 
5234 
5324 
5384 



(9 
( 9 
(10 
(10 
(10 
(11 
(11 
(11 
(11 
(11 



0) 
3) 
8) 
0) 

7) 
14) 

6) 

1) 

5) 

13) 

2) 

10) 

12) 

0) 

3) 

8) 

11) 

13) 



Remarks. 
Cow's milk, with spoon. 
Mother's milk, with spoon. 

u u u u 

Mother's milk direct from breast. 



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All the possible causes which may reduce the premature infant's vitality 
must be thoroughly understood and obviated. You must also appreciate 
that a failure to recognize and obviate one of these causes may defeat the 
benefit which may arise from attending to all the others. 

The premature infant should, so far as is possible, be restored to the 



PREMATURE INFANTS. 299 

condition that it has been forced out of, — namely, a condition of darkness, 
silence, and warmth. 

Yon see, therefore, that there are a great many points to be considered 
when you imdertake to treat intelligently an infant prematurely born, and 
it is this treatment which I shall endeavor to explain to you. 

AMOUNT OP FOOD AT BACH FEEDING.— I have already stated 
that the amount of food to be given at each feeding is very important. By 
referring to the weights and gastric capacities of the prematiu'e infants 
already described (Figs. 74, 75, 76, page 294), you will see how misleading 
is the weight of the infant if we take it as an exact index of the gastric 
capacity. We must, however, take the weight into accoimt, as, from even 
the very imperfect data at oiu* command, the weight of premature infants 
appears to bear a decided relation to their gastric capacity. AVe should 
at least be more inclined to increase rapidly the initial amount of food 
given in the case of an infant of large weight than in that of a small one. 
It is better to begin with too small rather than too large a quantity. By 
watching carefully for signs of hunger, a desire which the infant expresses 
by feeble but continuous cries, which stop when the food is given to it, 
we can gradually increase the amount until it seems to want it at regular 
intervals, is satisfied, and sleeps quietly during the intervals of feeding. 

By referring to these foetal stomachs (Figs. 73, 74, 75, 76), you will 
understand that it is safer to begin with 4 or 5 c.c. (about 1 drachm) and 
gradually to increase the amount up to a point where our very imperfect 
knowledge on this subject, derived partly from the weight of the infant, 
makes us believe that the stomach is full, than to begin at once with the 
larger amount. It is absolutely necessary that we should avoid undue dis- 
tention of the stomach, as this may prove fatal. 

INTERVALS OF FEEDING. — The premature infant's stomach is 
small, and is, in all probability, emptied quickly, and, as food is necessary 
for keeping up the animal heat required for the maintenance of its life, the 
intervals of feeding should be much shorter than those required for the 
infant at term. In the early days, and in fact weeks, of life, I have found 
that it is better to feed the premature infant regularly every hour. Fom- or 
five weeks after birth, if it is gaining in weight and is digesting well, these 
intervals can be so lengthened that by the time it arrives at term we can 
usually make the feeding intervals one and a quarter to one and a half 
hours, and a few weeks later two hours. 

COMPOSITION OF FOOD.— The careful adjustment of the pre- 
mature infant's food to its digestive organs is of even greater importance 
than in the case of the infant at term. There is no doubt that if we con- 
sider the h}^ersensitive condition and the undeveloped state of the digestive 
organs prior to birth, the most exact adjustment of the food to these 
digestive organs is absolutely necessary. This adjustment is best accom- 
plished by means of carefully prepared prescriptions at the ^lilk-Laboratory. 
Through this instrument of precision three important advantages are gained : 



300 PEDIATRICS. 

(1) we insure a clean food free from micro-organisms ; (2) we can obtain low 
and properly balanced percentages of the constituents of the milk ; (3) we 
have, at any time, the power of exactly varying, to within a fraction of one- 
half of one per cent., the percentages of the three most important elements 
of the milk, — namely, the fat, the sugar, and the proteids. In addition to 
these latter two advantages possessed by the substitute over the maternal 
method of feeding are others of almost equal importance. One advantage is 
the absence of variation in the substitute food arising from emotional causes, 
and another is that the infant need not be taken from the incubator to be 
fed. 

This prescription (Prescription 30) is the one which I should begin with 
in feeding an infant premature from the twenty-eighth to the thirty-sixth 
week : - 

Prescription 30. 
R Fat 1.00 

Sugar 3.00 

Proteids 0.50 

24 meals, each 4 c.c. (1 drachm). 

Heat to 75° C. (167° P.). 

Eeaction faintly alkaline. 

If the infant is over twenty-nine weeks, or if it is unusually large for 
its age, and especially if it is unsatisfied, it is well in a few days to change 
the prescription to this one (Prescription 31) : 

Prescription 31. 

R Pat 1.50 

Sugar ^ 4.00 

Proteids . 0.50 

24 meals, each 8 c.c. (2 drachms). 

If the infant is over thirty-two weeks, vary the prescription in a few 
days, under the same conditions as in Prescription 31, to — 

Prescription 32. 

R Fat 1 50 

Sugar 5.00 

Proteids 

24 meals, each 12 c.c. (3 drachms). 



0.75 



If the infant is over thirty-six weeks, the milk should, after forty-eight 
hours, be increased and strengthened to — 

Prescription 33. 

R Fat 2.00 

Sugar 5.50 

Proteids 1 00 

24 meals, each 16 c.c. (4 drachms). 



PREMATURE INFANTS. 301 

The infant^ however, under all circumstances, must be watched critically, 
and any or all of the percentages of the elements or amounts of the food 
increased or decreased according to the individual indications. 

When the infant is born at the thirty-eighth or thirty-ninth week its 
development is usually so near that of the infant at term that the incubator 
will not be needed, and the food can be given in about the proportions 
which would be adapted to the early days of the infant at term (Prescription 
3, page 181). 

"WEIGHING. — A knowledge of the weight of the infant is exceedingly 
important in the management of its feeding, and changes in the degree of 
its vitality take place so rapidly that the daily increase or decrease in its 
weight becomes the principal index by which we are guided in changing the 
food. 

The handling, however, which is necessary to obtain the daily weight is 
often a serious obstacle to the maintenance of its vitality. We should, 
therefore, endeavor to obtain the weight without reducing the vitality. The 
means for doing this I shall describe later. 

CLEANSING AND CLOTHING.— A premature infant should not 
be bathed beyond what is necessary for simple cleanliness. 

It should not be dressed, but should be wrapped in absorbent cotton. 
The cotton soon cleanses it thoroughly, and, if changed twice daily, or 
oftener if necessary, supplies the place of both clothes and bath. As a rule, 
no oil or ointment should be applied to its skin. 

INCUBATORS. — I have already told you, when speaking of milk- 
laboratories, that it is better not to spare expense in obtaining the very best 
means for preserving life which comes within our power. If you appreciate 
this great principle, which lies at the root of all successful methods of pre- 
serving the lives of premature infants, you will understand that even the 
smallest details which I have spoken of, and which I shall again mention 
more at length, are not to be considered trivial or beneath your earnest and 
careful attention. The premature infant's life is so difficult to preserve 
that we should make use of every device which our ingenuity can suggest. 
From the very moment it enters the world its viability is likely to be 
brought to an end, and every minute is of importance in our endeavors 
to combat this tendency. We should, therefore, be ready to protect it at 
once from the adverse influences which surround it. We should have 
decided views of how to treat this early period of life, and also have 
the means which we think should be best employed ready to be supplied 
at once. 

In the treatment of premature infants only one of the principal methods 
of maintaining their viability usually receives much attention. It is com- 
monly supposed that if the atmosphere which surrounds the infant is kept 
at a sufficiently high temperature all that is requisite lias been done for its 
safety. This until very recently has been accomplished by placing the 
infant in a room where the temperature is as high as the nurse in charge 



302 PEDIATRICS. 

of it is able to endure. This procedure is necessarily a very uncomfortable 
one for the nurse, and at times renders it almost impossible for her to use 
her mind intelligently. It also requires a much more frequent change of 
nurses than would be the case if the atmosphere of the nursery were cooler. 
In addition to this means of preventing undue loss of heat, the infant is 
wrapped in cotton-wool and placed in a basket lined with hot-water bottles, 
or it is placed at once in an apparatus which is called an incubator. These 
incubators have been used for many years in different parts of the world, 
notably in Paris. They are of different forms, which I need not describe 
here, as there is nothing especially important to recommend about them 
when we compare them with the latest form of incubator, which I shall 
presently describe to you (Fig. 80, page 306). The purpose of them all is 
the same, — namely, to keep the infant warm. Some of them are made of 
tin, with double walls, so that hot water can be continually kept in them, 
and thus sufficient warmth be applied to the infant. Others are made of 
wood, and kept warm by means of hot-water bottles introduced into them 
from below. None of them combines in the best way the many requisites 
necessary to preserve the premature infant's life. 

The name incubator has been applied to these various devices for keep- 
ing up the animal heat of the infant. It is a misnomer, for incubation 
means hatching, and, in the precise sense of the word, the premature infant 
is already hatched and has been incubated. What we accomplish by this 
apparatus is analogous to what is done to keep up the animal heat and 
preserve the lives of young chickens after they are hatched, and the name 
brooder would be more applicable to machines devised for preserving the 
lives of premature infants than the term incubator . The word incubator is, 
however, so generally used to represent an apparatus intended to preserve 
the premature infant's life until it has attained the age of two hundred and 
eighty days, that it will, in all probability, for the present be retained. The 
true meaning, however, of what I am endeavoring to explain to you is so 
much better expressed by the word brooder, meaning warming, and not 
hatching, that I shall use it in speaking of the latest apparatus which has 
been invented for the purpose of human brooding. 

Before speaking of the treatment of premature infants where every de- 
tail can be carried out in the most approved manner, I shall mention a few 
cases which illustrate the different points to which I have just referred. 
For instance, where it is impossible to obtain an incubator at once for pre- 
serving the premature infant's animal heat, it must be treated in the way 
which I have already referred to, by placing it in a room where the tempera- 
ture has been raised to 32.2° C. (90° F.). 

I have here a picture (Case 106) representing an infant premature at the seventh 
month, and now fourteen weeks old. 

It is in this basket, enveloped in cotton-wool, and covered with blankets. You see 
that the thermometer is kept in the basket beside it, and the nurse has continually to 
watch it. 



PREMATURE INFANTS. 



303 



It was under the care of Dr. Hunt, of West Newton, with wh» m I saw it in consul- 
tation. It was placed in the incubator when it was four weeks old. It was taken out of 
the incubator when it was twelve weeks old. At this time it had gained very little in 



Fig. 77. 




. Infant premature at twenty-eighth week. Birth-weight, 1200 grammes. Present age, fourteen weeks. 
Treated in basket heated by hot-water bottles. Temperature of air in basket shown by thermometer in- 
troduced between side of the basket and the blanket. The infant was removed from the incubator when 
it was twelve weeks old. 

weight, was emaciated, puny, and feeble. Its abdomen was much distended, and its skin 
wrinkled, dry, and yellowish in color. 

Here is a picture (Fig. 78) of this infant taken when it was fourteen weeks old, 
which shows the senile expression of the face so characteristic of premature infants at 
birth, and later when they are not thriving. 



Fig. 78. 




Infant premature at twenty-eight Aveeks. Present age, fourteen weeks. 



Here is another picture (Fig. 79) of this infant, with its day nurse and its night nurse, 
its basket, and the scales on which it was weighed daily. 



304 



PEDIATRICS. 



This picture is instructive in making you appreciate how small this infant was, as is 
well shown by comparing the size of its head with that of the nurses' heads. 

Fig. 79. 




Infant premature at twenty-eight weeks. Present age, fourteen weekt= 



The next infant (Case 107) which I shall speak of was one which was prematurely 
born at about the thirty-third week. It was treated in a basket warmed with heaters, and 
in a room where the temperature was kept from 29.44° C. (85° F.) to 32.22° C. (90° F.). 
It was carefully nursed by a night nurse and a day nurse. 

It weighed 2490 grammes (about 5 pounds 3 ounces). It was under the care of Dr. 
Edward Eeynolds, with whom I saw it in consultation. Its food was carefully regulated 
at the Milk-Laboratory, and the first prescription which was written for it, and which 
proved to be adapted to its digestion during the first week or ten days, was this one (Pre- 
scription 34) : 

Prescription 84. 

R Fat 1.00 

Sugar 3.00 

Proteids 1.00 

Lime water 5.00 

The mixture to be heated for twenty minutes at 68.38° C. (155° F.). 

From my later experience with these cases, I should begin with the percentage of pro- 
teids 0.50, as I have already described in this prescription (Prescription 30, p. 300). In the 
early days of this infant's life oxygen had to be administered to it for two or three minutes 
every hour. It was fed every hour, and received six drops of brandy with each feeding. 
At my first examination, which was made when it was six hours old, a distinct cardiac 
murmur was heard at the base of the sternum, and there were a few fine moist rales through- 
out both lungs. The murmur and the rales disappeared in the course of a week, and the 
infant, after losing 135 grammes (about 4J ounces) in the first three days, began to make 
small gains in weight, and when it was seven weeks old it weighed 2730 grammes (about 
5 pounds 11 ounces), was plump, had a healthy color, and seemed very well. It began to 
perspire when it was seven weeks old. 

This case received the very closest attention, and was treated with all the details for 
safety which were possible to be attained without the use of an incubator, but we must 
consider that its weight, 2490 grammes (about 5 pounds 3 ounces), and its age, thirty- 



PREMATURE INFANTS. 305 

three weeks, were such as to make the preservation of its life a much more simple matter 
than that of the infant (Case 106) whose picture I have just shown you, and whose light 
weight pointed towards so undeveloped and premature a condition that any omission in re- 
gard to the closest detail of treatment would have been likely to prove fatal. 

This infant had progressed so far in its general condition and development that at the 
age of eight weeks it was taken out of the cotton in which up to that time it had been 
wrapped and was dressed. At this time it was taking 56 c.c. (If ounces) at each meal, and 
was fed once in two hours. 

The next case (Case 108) is that of an infant which was four weeks premature, and 
which was, for a premature infant, tolerably vigorous at birth. It was under the care of 
Dr. Samuel Breck, with whom I saw it in consultation. It was not placed in an incubator. 
Unfortunately, its nurse had no idea of the importance of protecting it from external influ- 
ences. It was fed on a carefully prepared food from the Milk-Laboratory, and began to 
gain in weight, and in every way showed no evidence of its vitality being interfered with ; 
but the nurse was possessed with the idea that it needed plenty of cold fresh air. The 
window in the infant's room was left open one night when the weather was quite cool. 
The following day it did not take its food well, was somewhat cyanotic, and was found to 
have lost almost 240 grammes (| pound). It was then placed, as it should have been in 
the beginning, in a warm room, treated with the utmost care, and not handled much. None 
of these measures, however, were sufficient to prevent a still further lessening of its vitality. 
It never rallied from the first blow which was struck at its vitality, and lost its life practi- 
cally through the ignorance of the nurse who was in charge of it. 

A post-mortem examination showed nothing abnormal, except that the mesenteric 
glands were somewhat enlarged. 

The next case (Case 109) was that of an infant born at about the twenty-fifth week of 
intra-uterine life. Its weight was 1080 grammes (about 2^ pounds). There are a number 
of interesting points to be recorded in this case. 

It was not strong enough to suck, and had to be fed with a spoon. Its mother's milk, 
the analysis (Analysis 55) of which I have here to show you, at once caused such disturb- 
ance that modified milk from the Laboratory had to be substituted. 

ANALYSIS 55. 

Fat 1.29 

Sugar 4.10 

Proteids 6.83 

Ash 0.26 

Total solids 12.28 

Water 87.72 

100.00 
This is the prescription for the modified milk which it digested well : 

Prescription 35. 
Modified Milk. 

R Fat 1.00 

Sugar 3.00 

Proteids 0.75 

The infant's temperature in the rectum was 36.7° C. (98° F.). It seemed to be doing 
fairly well, but did not gain in weight, and on the fifth day of its life was unable to swal- 
low. It was then fed by gavage. 

It was treated with great care so far as keeping it warm was concerned, but an incu- 
bator could not be obtained for it, and it died when it was seven days old. 

It is interesting in this case to notice that the meconium came as is usual in the infant 
at term, and began to change its color on the third day, and that by the fifth day the fsecal 
movements were yellow and well digested. 

20 



306 



PEDIATRICS. 



These particulars were given to me by Dr. Woods, who was in charge of the case. Its 
death was evidently due to the lowering of its vitality consequent upon its age and lack of 
sufficient development to withstand the influences surrounding it in extra-uterine life. 

I now Avish you to examine this incubator (Fig. 80), which was devised 
by Dr. Worcester, of Waltham, Massachusetts. It is far superior in its 
mechanism and in its general utility to the other incubators which I have 
already referred to, except that of Tarnier, which it closely resembles. 
It is practically a wooden box, 76 cm. (2| feet) long, 45.5 cm. (IJ feet) 
wide, and 76 cm. (2 J feet) high. This box, as you see, has a glass lid, 
which can be raised when necessary, but which is intended to be kept closed 
and to be used as a window through which to observe the infant. Two or 

Pig. 80. 




To left of incubator is the oxygen tank. To left of incubator on the floor is the lamp, 
end of incubator is au anemometer. 



At upper right 



tiiree holes at the end and at the bottom of the box allow the entrance of 
air. A hole at the top and end of the box, fitted with an anemometer, 
serves as an exit for the air. The continuous motion of the anemometer 
shows that the ventilation is being carried on properly. At the bottom of 
the box is a metallic boiler. A pipe from this boiler is brought through the 
end of the box, turns upward for a few inches, and then turns back and 
enters the box, where it connects again with the boiler. Outside of the end 



TABU 

Shoivlng Details of Si.ciy-Fonr Days of Life iit the 



Days Intervals 
of between 
Life. Meals. 



1 hour. 
1 hour. 
1 hour. 
1 hour. 

1 hour. 

1 hour. 

1 hour. 

1 hour. 
1 hour. 
1 hour. 
1 liour. 
1 hour. 



AMorNT 

at each 

Meal. 



C.c. Dr'ms. 



Percentages of Food. 



F.ECAL Discharges. 



Fat. ' Susrar. 



1 hour. 8-10 2-21^ 
1 hour, i S-10 '1-1% 
1 hour, i 12 ! o 



1 hour. 
1 hour. 
1 hour. 
1 hour. 
1 hour. 
1 hour. 
1 hour. 
1 hour. 
1 hour. 
1 hour. 
1 hour. 
1 liour. 
1 hour. 
1 hour. 
1 hour. 
1 hour. 
1 hour. 



12 

12 

12 

12-14 

1(5 

l(i 

1(M8 

lf)-l« 

18-20 

18-20 

18-20 

18-20 

20 



24-2G 



1 hour. 28 
VA hr.>. 32 



:3G ; 134 lirs. 



\\i hrs. 

IK li''-- 
VA hrs. 
VZ hrs. 
VA hrs. 
VA hrs. 
V/^ hrs. 
\% hrs. 
V/, lirs. 
V/, hrs. 
\% hrs. 
V4 hrs. 
VA hrs. 
\% lirs. 
VX, \\Y*. 

1% hrs. 
ik hrs. 
\% hrs. 
1% hrs. 
\% hrs. 
\% hrs. 
\% hrs. 
V% I.rs. 
Vy. hrs. 
\% hrs. 
I'M hrs. 
r%-l hrs. 
I'v 2 hrs. 

1 = , -'I'rs- 
r,'< 2 hrs. 



3 

3-3)^ 

4 

4 

4-43^ 

4-43^ 

43^-5 
43^-5 
4K-5 
5 

53| 
■^^ 
6-(i% 



I 1 



1.00 
1.00 
1.00 
1.00 

1.00 

1.00 

1.03 

1.00 
1.00 
1.00 
1.00 
1.00 

1.00 
1.00 
1.50 

1..50 
1.50 
1.50 
1.50 
1.50 
1.50 
1.50 
1.50 
2.00 
2.00 
2.00 
2.00 
2.00 
2.00 
2.00 
2.00 
2.00 

2.00 
2.00 

2.00 

2.00 
2.00 
2.00 
2.00 
2.00 
2.00 
2.00 
2.00 
2.00 
2.00 
2.00 
2.00 
2.00 
2.00 
2.00 
2.00 
2.00 
2.00 
3.00 
3.(n 

3.o:) 
3.00 
3.00 
3.00 
3.00 
3.00 
3.00 
3.(»0 
3.00 
1.00 



3 per ct. 
sol. in 

aq. dls. 
3.00 
3.00 
3.00 
3.00 

3.00 



3.00 

4.00 
4.00 
4.00 

4.o;) 

4.00 

4.00 
4.00 
5.00 

5.00 
5.00 
5.00 
5.00 
5.00 
5.00 
5.00 
5.00 
5.00 
5.00 
5.00 
5.00 
5.00 
5.00 
5.00 
5.00 
5.00 

(> 00 
G.OO 

G.OO 

f).00 
0.00 
(i.OO 
(i.OO 

(i.o;) 
o.oo 

(1.00 
(i.OO 

(;.oo 

(i.OO 
(i.OO 
(i.OO 
(i.OO 

(i.do 

(1.00 
(i.OO 
(i.OO 
(i.OO 
7.(10 
7.00 
7.(10 
7 0) 
7,00 
7.(10 
7.011 
7.00 
7.00 
7.00 
7.00 
7.00 



Proteids. 



1.00 
1.00 
1.00 
1.00 

1.00 

1.00 

1.00 

1.00 
1.00 
1.00 
1.00 
1.00 

1.00 
1.00 
1.00 

1.00 
1.00 
1.00 
1.00 
1.00 
1.00 
1.00 
1.00 
1.00 
1.00 
1.00 
1.00 
1.00 
1.00 
1.00 
1.00 
1.00 

1.00 
1.00 

1.00 

1.00 
1.00 
1.00 
1.00 
1.00 
1.00 
1.00 
1.00 
1.00 
1.00 
1.00 
1.00 
1.00 
1.00 
1.00 
1.00 
1.00 
1.00 

1.00 

1.00 
1.00 
1,00 
1.00 
1.00 
1.00 
I.O) 
1.00 
1.00 
1.00 
1.00 



Lime 
^^'ater. 



No. 



5.00 
5.00 
5.00 
5.00 

5.00 

5.00 

5.00 

5.00 
5.00 I 
5.00 
5.00 
5.00 

5.00 
5.00 
5.00 

5,00 
5 00 
5.00 
5.00 
5.00 
5.00 
5.00 
5.00 
5.00 
5.00 
5.00 
5.00 
5.00 
5.00 
5.00 
5.00 
5.00 

10.00 
10.00 

5.00 

5.00 
5.00 
5.00 
5.00 
5.00 
5.00 
5.00 
5.00 
5.00 
5.00 
5.00 
5.00 
5.00 
5.00 
5.00 
5.00 
5.00 
5.00 
5.00 
5.00 
5.00 
5.00 
5.00 
5.00 
5.00 
5.00 
5.00 
5.00 
5.00 
5.00 



Character. 



nieconuim. 
brown, small. 



only fairly 
dige.sted. 



yellow. 

well digested. 



slightly green. 



yellow and 
well digested. 



W'ght. 



Oz. 



23< 

8 

9 



Weight. 







Gr'ms. 


Lbs. ; 


2040 


4 ; 


2040 


4 ; 


2040 


4 i 


2040 


4 


2010 


4 : 


2040 


4 ; 


2040 


4 


2055 


4 ; 


2010 


4 : 


2025 


4 ; 


2025 


4 ; 


2055 


4 : 


2070 


4 ; 


■ 2070 


4 : 


2070 


4 


2160 


4 ■ 


2160 


4 


2100 


4 


2130 


4 


2160 


4 


2175 


4 


2220 


4 


2235 


4 . 


2250 


4 ; 


2280 


4 ; 


2280 


4 ; 


2295 


4 ! 


2310 


4 ; 


2310 


4 ; 


2280 


4 ; 


2287 


4 : 


2295 


4 : 


2295 


4 ; 


2295 


4 ; 


2340 


4 ; 


' 2400 ' 


' 5 ' ^ 


2460 


5 i 


2490 


5 : 


2520 


5 : 


25,50 


5 : 


2550 


5 ; 


2550 


5 ; 


2640 


5 : 


2700 


5 ; 


2700 


5 : 


2640 


5 : 


2640 


5 ; 


2730 


5 ! 


2790 


5 : 


28,50 


5 


2850 


5 


2880 


6 


2880 


6 : 


2970 


(i : 


2970 


(i ; 


3030 


(i 


3030 


6 


3090 


(i 


3120 


() 


3210 


(i 


3150 


(! ; 


3240 


() ■ 


3240 


(i 


3270 


6 


3270 


(i 


3300 


6 



W. .six nioiilhs wi'igiii'd 70M) granuues (11 pouuds 12 ounces) and was taking 150 c.c. (5 ouiK 



i.E 82. 

'Incubator of Ca^c 110, Preriiaturc at TJiirty Weeki 



rEMPERATURE 

(Rectal). 



°C. 



Pulse. 



OR 
99.5 



o9.2 i 102.5 
37.5 99.5 



99.5 
100.5 



135 



, Temperature 
Resp. 1 OF 

I>'CUBATOR. 



GO 



50-60 



120 
120 



99.0 
98.8 



36.9 98.5 



120 



140 



101 



99 

99 

99.5 
101.5 
101) 

98.5 



99 

98 

99.5 

99.5 

99 

99 

99 



99 



138 



40 



°C. 
32.2 



32.2 
32.2 
32.2 
32.2 

28.3 

26.6 

26.6 

26.6 
26.6 
26.6 
26.6 
26.6 



- . . . 28.8 
. . . . I 28.8 
60 I 29.4 



28.3 
28.3 

26.6 
29.4 
29.4 
26.6 
26.6 
26.6 
26.6 
26.6 
25.5 
25.5 
23.8 
23.8 
2:3.8 
23.8 
23.8 
23.8 
23.8 
23.8 
23.8 
23.8 
22.2 
22!2 
22.2 
22.2 
22.2 
21.1 
21.1 
21.1 
21.1 



90' 



80 



80 
80 
80 
80 
80 

84 
84 
85 

85 
85 
85 
85 
85 
85 
85 
85 
85 
85 
85 
85 
85 
85 
85 
85 
83 

83 
83 

80 
85 
85 
80 
80 
80 
80 
80 
78 
78 
75 



Remarks. 



Nails formed. 
Cry feeble. 



No lanugo. Heart nonual. Lungs normal. Emaciated. 



Uric acid on napkin. Food heated to 75° C. (107° F.). 

Somnolent. 

No uric acid. Fed with dropper. 

Temperature went up in evening. Perspired freelv. Temperature of in- 
cubator lowered to 28.3° C. (85° F.). Hiccoush relieved bv brandv 

Respirations irregular ; 10 quick and then imperceptible for 10 seconds 
Cord fell. Somnolent. 

Cry a little stronger. As still perspiring a little, temperature of incubator 
reduced to 26.6° C. (80° F.). 

Slight ophthalmia neonatorum. Icterus neonatonim. Black cloth over 
lid of incubator. 

Somnolent. 

Less icterus. 

Hiccough. 

Hands and feet cold. 

Hands and feet warmer. Oxygen in fresh-air-box for 10 minutes three 
times daily. Seems hungrv. 

Every other feeding takes 23^ drs. Oxvgen as on 13th. 

Oxygen as on 13th. 

Oxygen 5 minutes twice dally. Feet cold when incubator below 29.4° C. 
(8o°F.). 

Less icterus. 
Oxygen. 

Very hungry. Oxygen. 

Oxygen. 
Occasional cyanosis. 



Oxygen. 



Brandy 5 drops everj- 2 hours. 

Feet and hands not cold except when temperature of mcubator as low 

as 26.6° C. (80° F.). Seems himgry. 
Oxygen. Brandy 5 droits three times dailv. 
Brandy 5 drops three times daily. Oxygen. Began to feed with nipple. 

Respirations deeper and more regular. Slight cyanosis. Oxygen. 

Oxygen. Brandy 5 drops. 

Oxygen. Brandy 5 drops every other feeding. 

Allowed to have a little light in incubator. Omit oxygen. 

Oxygen. Brandy. Somnolent. 

No light. 

Is brighter. Oxygen. 

Oxygen. Brandy. 
Seems stronger. More light. 
Oxygen. 
Brandy. 
Seems "hungry. 
Oxygen. 
Oniit oxygen. 

Sleeps aiid takes food well. Seems stronger and brighter, and is tranquil. 
Does not cry. 

Very bright and tranquil. 

Taken out of incubator. Cried 9 hours. Vomited. Put back into incubator. 

Tranquil. Does not cry. 

Taken out of incubator and washe<l in water at 35° C. (95° P.). 

Sleeps well. Does not crv. Is growing stronger. 

Thriving. Brandy omitted. 



:'es) at each meal. Looked bright, had a good ('()h)r, and was well devolojied and vigorous. 



PREMATURE INFANTS. 307 

of the box there is a pipe by means of which the boiler can be filled with 
water. A stop-cock allows the water to run off from the boiler when it is 
necessary to empty it, or to regulate the heat of the water by allowing the 
cold water to flow out and warm water to replace it. A lamp of any kmd 
placed imder the arm of the pipe which comes from the boiler keeps up and 
regulates the warmth of the water in the boiler. I would here call attention 
to the fact that when the som^ce of heat is outside of the incubator there is a 
danger that the free flame may set fiire to the nurse's dress. 

Above the boiler is a shelf, on which the infant's bed is placed, sufficient 
space being left between the ends of the bed and the box for a free cumula- 
tion of the contained air. 

A thermometer is attached to the water apparatus of the boiler, and 
indicates the heat of the water. 

A thermometer is attached to the lid of the box, and is intended to show 
the temperature of the au* in the box. 

I have here a picture (Fig. 80) of an infant (Case 110, page 306) in 
this incubator, prematurely born at about the thirtieth week of intra- 
uterine Life. 

The lid of the incubator Is open, representing a time when the infant is to be fed. On 
the left of the incubator part of the oxygen tank is shown. On a table beside the incubator 
are the measuring glasses, a glass tube with a cotton stopper containing the infant's food, 
which was prepared at the Milk-Laboratory, a pitcher of warm water to keep the food warm, 
and the teaspoon with which the infant was fed. In the bed beside the infant you will see 
that there is another thermometer, which it was found necessary to use, as the thermometer 
attached to the lid was subject to such variations in temperature through the glass, accord- 
ing to the variations of the temperature in the room, that it did not indicate exactly the 
temperature of the air by which the infant was surrounded. In the treatment of this 
infant in the incubator much difficulty arose in keeping the ventilation perfect, and at 
times the air for hours had to be forced through the air-box by fanning the air through the 
holes of entrance. 

This infant was taken care of in an unusually exact way, and with such intelligence 
on the part of the nurses and parents that the details of its life in the incubator become 
of extreme value in our study of the treatment of this class of cases. I shall therefore 
describe the details of its existence in the incubator from the time when it was born until 
it was sufficiently developed to be safely taken care of in the ordinary way. 

The infant and its mother were under the care of Dr. George Haven and Dr. TV. L. 
Eichardson, with whom I saw it in consultation in the early hours of its life and by whom 
it was placed in my charge. At birth its nails were fairly developed. Its face was not 
especially wrinkled, but its body and limbs did not show much evidence of subcutaneous 
fat. The lanugo was not present. Its weight was 2040 grammes (about 4^ pounds). On 
comparing this weight with the weights given in this table (Table 2, page 49) of the 
relation of weight to vitality, you will see that it is representative of that of an infant 
at term of very low vitality. The heart and lungs were normal. No cardiac souffle was 
heard over the area of the foramen ovale. The cry was rather feeble. The infant was very 
somnolent. 

I think you will be able to understand the details of this case most clearly if I arrange 
them for you in the form of a table (Table 82). 

The table records the details of the infant's life in the incubator during 
a period of sixty-four days. The record will, I think, be of great use to 



308 PEDIATRICS. 

any one who has charge of a premature infant in an incubator, as it illus- 
trates exactly what emergencies are likely to arise and how they can be met. 

The infant, as is seen by referring to the column of remarks, came 
very near dying a number of times, and unquestionably would have died 
had it not been carefully managed, as, for example, by the administration 
of oxygen, by prompt changes in its food, by the regulation of the temper- 
ature of the incubator, and by the constant attention of a day nurse and a 
night nurse. 

I have now in a general way told you the main facts which are known 
about premature infants, and the results of my experience with this class of 
cases. The last case (Case 110) which I have described as being treated in 
Dr. Worcester's incubator was the one from which I learned how very in- 
adequate are our usual methods of treating premature infants. In the 
direction of this case I received so much information as to the mechanical 
management of the many difficulties which were continually presenting them- 
selves in the daily care of the apparatus from Mr. J. P. Putnam, that it 
was at once impressed upon me that a domicile in which an infant might 
have to live for several months should be devised and regulated as to its 
ventilation and general practical usefulness even more carefully than the 
houses in which adults live. This meant that such apparatus needed the 
skilled attention of an expert in building and in ventilation. I therefore 
placed in Mr. Putnam's hands the construction of what I prefer to call a 
brooder. I am also indebted for many valuable suggestions as to the con- 
struction and use of the brooder to Mr. G. E. Gordon, who has had con- 
siderable experience in preserving the lives of premature calves. 

Before inspecting the brooder more closely I should like you to examine 
this table (Table 83), in which I have condensed what I have already told 
you concerning the requirements needed to preserve the lives of premature 
infants. 

TABLE 83. 
Indications for conserving the Viability of Premature Infants. 

I. There should be a receptacle which shall guard the infant from the deleterious 
influences of extra-uterine life. 

II. There should be an apparatus that can be obtained quickly and transported rapidly, 
and which therefore should be kept at some central and convenient station. 

III. The place where the brooder is kept should be free from the influence of any 



IV. The brooder should be so constructed as to make it possible for it to be absolutely 
cleansed and disinfected each time after it has been used, hence it should be made of metal. 

Y. The brooder should, as soon as the infant is placed in it, be under the observation 
of trained nurses night and day. 

YI. The food for the infant should be regulated with the greatest precision, with the 
closest attention to minute details, and, if possible, at a milk-laboratory. 

These are the principal rules which should be attended to where the 
physicians of any community wish to provide the best means for preserving 
the lives of the premature infants in that community. The expense of such 



PREMATURE INFANTS. 



309 



means, while too great for any one individual, 4s comparatively insignifi- 
cant for a number. The brooder at present must necessarily be an expen- 
sive machine, but if provision should be made for it in combination with 
such scientific facilities for infant feeding as I have already recommended, 
I believe that any community w^ould find it of infinite benefit. I am also 
sure that there would result saving of life for the people, and saving of 
time and expense for the physicians, combined with the greatest satisfaction 
to both people and physicians. Such a combination, in cities of a milk- 
laboratory or in the country of a Babcock milk-tester with a brooder kept 
in one central station, I hope to see established everywhere. One such 
station for districts which might be included in a radius of ten or even of 
twenty miles would be amply sufficient to accomplish very favorable results. 

BROODER. — You will now, I hope, appreciate that it is often quite 
necessary to provide not merely a receptacle but an actual habitation for 
premature infants during a pe- 
riod of months. Such a habi- ^ Fig. 81 
tation, w^hich I prefer to call a 
brooder in order to represent it 
by the name which explains it 
rightly, I have here to show 
you (Fig. 81). 

This apparatus has been 
made to fulfil the conditions of 
a house for the premature in- 
fant, and it practically meets 
the indications called for in this 
table (Table 83, p. 308). After 
being used, it can be completely 
disinfected and cleansed. It is 
kept at the Milk-Laboratory, 
whence it can be obtained at a 
moment's notice. For pur- 
poses of disinfection, and that 
it may not absorb micro-or- 
ganisms or dirt of any kind, which in wooden receptacles invariably cause 
a decided odor, it is made entirely of metal. 

The brooder is supported, as you see, on three wheels, preferably made 
of light steel, two behind and one guiding wheel in front. A handle is used 
to push it to different parts of the room, or, if necessary, to an adjoining 
room, so that the mother can see her infant if she is too sick to leave her 
bed. The top of the brooder is about 91 cm. (3 feet) from the floor, so 
that the nurse does not have to stoop unnecessarily, but at the same time 
can, when sitting down, see into it from above. It is 76 cm. (2 J ieoX) wide 
and 91 cm. (3 feet) long. The body is made of copper ; the walls are 
double, and insulated on the outside, to prevent radiation. The water used 




Brooder for premature infants. A, scales for weighing in- 
fant ; B, glass lid of incubator ; C, fresh-air box, contain- 
ing clock-work and fan ; D, lamp for heating water-jacket ; 
E, chimney ; F, return flue from heating-flues : G, return 
fresh-air flue ; H, entrance for fresh air ; I, connection for 
oxygen tank ; J, mixing-valve ; K, ventilating exit ; L, 
anemometer. 



310 PEDIATRICS. 

for heating circulates on all sides, and the infant is thus warmed by direct 
radiation. The top of the brooder is covered in the middle by a thick plate- 
glass lid, which can be raised sufficiently to allow the hands and arms of the 
nurse to be freely used in the brooder, and is by a simple contrivance kept 
from falling down while the infant is being fed or touched. A chain pre- 
vents the lid from falling backward. On the under side of the glass lid is 
a fine wire sliding screen, which comes directly over the infant's head and 
between it and the glass. This is simply a precaution against the possible 
breakage of the glass lid and consequent injury to the infant. 

This plated box (C), which you see attached to the upper front end of 
the brooder contains some strong clock-work with a fan attachment. This 
oval opening in the clock-box admits the air to the brooder. Below the 
opening for the fresh air is a window, through which the fan and clock-work 
can be watched. 

Just below the air-opening and above the clock-work is a fine open wire 
shelf, on which is spread a thin layer of cotton-wool. The air, which by 
means of the fan is drawn into the box, is sifted through the cotton and 
carried down the air-shaft {H) directly into the brooder. In this air-shaft 
(H) you see there is a small stop-cock (J). This is the point of attachment 
for the tube from the oxygen tank, to be used when oxygen is needed to be 
mixed with the entering air-s apply. 

In this air-shaft, also, is attached a valve, which is so regulated by a 
register handle that the air can be utilized either above or below the boiler, 
according as it is needed and as I shall explain later. 

The bottom of the brooder constitutes an air-chamber, and in this is a 
boiler which, with its heating or combustion direct and return flues, warms 
the interior of the apparatus. 

Above the boiler is placed the platform of a scale. The balance power 
of this scale is on the top of the back end of the brooder. The platform of 
the scales acts as the support for a metal pan 61 cm. (2 feet) long and 30.5 
cm. (1 foot) wide, on which the infant is placed. This pan should be made 
of sheet iron, enamelled on both sides with white porcelain enamel, and 
should have handles at either end to facilitate its removal from the brooder. 
From the ends of this pan is hung by wires, which can be easily attached 
or detached, a light frame made of four steel rods crossed. On this frame 
is tied with tapes a piece of strong cotton cloth. This cloth is the infant's 
bed, on which it is placed wrapped in clean absorbent cotton. This cotton 
cloth is about 2.5 cm. (1 inch) above the bottom of the pan. The infant's 
head is turned to the back end of the brooder. 

At the front end, opposite the foot of the infant's bed, is the exit (G) for 
the vitiated air. This exit passes through the end of the brooder and 
enters a ventilating pipe which has at its top an anemometer (X). The 
bottom of the shaft is outside the brooder, and has a closed cone-shaped 
end, which is enclosed in a metal box in such a way that a lamp (D) can be 
placed under it. The heat from this lamp answers two purposes. One is. 



PREMATURE INFANTS. 



311 



by keeping the ventilating shaft hot, to aid the ventilation, and the other is 
to heat the water in the boiler. A register-valve (J) attached to the pipe 
€an shut off the heat if necessary from the boiler, and allow it to go 
directly up the double pipe (E, K), whereby its entire power will be used 
in promoting ventilation, or the valve may be set so as to direct the flame 
partially into the boiler, thus placing its temperature completely under con- 
trol. In this way the heat from the lamp (which is enclosed in the box) is 
without danger entirely utilized for heating and ventilation. 

I have now shown you the brooder and its general features. I shall 
still further explain to you its mechanism by means of this sectional dia- 
gram (Diagram 6). 

Diagram 6. 

^l/^SS PLATE i //v. m/CK 




Section of brooder. L, lid of fresh-air box, open ; A, entrance of fresh air ; C, cotton, resting on wire 
shelf above clock-Avork ; F, clock-work and fan ; S, valve regulating hot and cold fresh air ; 0, pipe for 
oxygen attachment; C. F., cleaning-flue; Boor, door to lamp-box; W, wire frame to protect against 
breakage of lid. 

The smoke-flue of the lamp, marked ^^ Heating Flue,'' passes through 
the centre of the boiler, marked " Water'' in the diagram, as far as to the 
cleaning-flue, marked C. F. Thence it returns and enters the upright 
pipe marked '^Heating Flue Exit." The horizontal return-flue is not 
shown in the diao-ram, because it is behind the horizontal arm shown. The 
little gate-valve shown directly above the lamp regulates absolutely the 
amount of heat which is allowed to pass through the boiler, and the tem- 
perature of the Avarm water therein may be tested by a chemist's ther- 
mometer, inserted at any opening which may be provided for it as directed 
when the brooder is built. 

The fresh-air flues are constructed, as shown, one above and one below 
the boiler. One flue comes in contact with the upper or hottest part of the 
boiler, and presents a very large surface of contact therewith by being flat- 
tened so as to cover completely the upper side of the boiler. The other 
flue touches the bottom of the boiler onlv in one line, or not at all, so that 



312 PEDIATRICS. 

the air passing through it is practically unaffected by the boiler heat. By 
this arrangement the temperature of the fresh air can be regulated at will 
by the attendant by simply raising or lowering the valve S. 

In virtue of the large amount of heating surface of the heating flue in 
this apparatus, it is found that a very small flame suflices to keep up the 
desired temperature, and it results from this that no injurious products of 
combustion contaminate the air of the room. A very small alcohol lamp 
can be used, while with a less scientific arrangement this fuel might be 
found too expensive. 

It is probable that an electric current will be found most suitable to 
supply the heat in place of the lamp, as well as to drive the fan, and this 
can be very easily accomplished with a small battery. 

By packing the water-jacket with asbestos, external radiation is pre- 
vented. 

The heating of the brooder varies as to time and degree according to 
the atmosphere of the room where it has been standing. If, however, the 
temperature of the room is 21.1° C. (70° F.), and the temperature of the 
water which is introduced into the boiler is about 40.5° C. (105° F.), it 
will be found that after the cool air in the brooder has been displaced the 
temperature of the air in the brooder will in about fifteen minutes rise to 
35° C. (95° F.). The temperature will remain at this point for about half 
an hour. As soon as the temperature begins to fall the alcohol lamp should 
be lighted, and as soon as the temperature of the water in the boiler rises 
above 35° C. (95° F.) the lamp should be extinguished. By careful regu- 
lation of the lamp and regulating the fresh air by means of the register- 
valves, an intelligent nurse can keep the temperature of the brooder at 
whatever degree the physician orders. The thermometer should, in order to 
show accurately the temperature of the air which the infant is breathing, be 
beside it on its bed, as when attached to the lid it is influenced by changes 
of temperature in the room. 

If any difliculty arises from the temperature not responding quickly 
enough to the register- valves and lamp, it is well to draw off' a little hot 
water and replace it by some cold water if it is desired to lower the tem- 
perature, while to raise the temperature the withdrawn water is to be replaced 
by hot water. 

Nurses. — The brooder is not intended to obviate the necessity of 
skilled nursing. On the contrary, a nurse should be in constant attend- 
ance night and day. She should have all the details of the infantas care 
and the mechanism of the brooder explained to her minutely, for an emer- 
gency may arise at any time, and always requires to be dealt with 
immediately. 

The brooder supplies the means for exact treatment, but intelligent 
minds and trained gentle hands are indispensable. The nurse should fre- 
quently observe the infant through the glass lid, and should be certain that 
the anemometer is in constant motion. 



PREMATUEE INFANTS. 



313 



Fig. 



Apparatus connected with the Brooder. — A stethoscope like 
this one (Fig. 85, p. 323) is the best adapted for examining the infant in 
the brooder. It can be bent in any direction, and the small calibre of its 
cup is best adapted to the infants size. 

A piece of dark cloth should be kept over the glass lid, to preclude the 
light, while the sun should be allowed to shine freely into the room. 

The method of feeding the infant in the brooder is important. It fre- 
quently happens that the premature infant is too weak not only to suck the 
breast, but also to be fed from the bottle. In such cases it is customary to 
use a spoon or a medicine-dropper. These, however, are very unsatisfactory 
instruments. The food is liable to be spilled, the spoon or dropper has to 
be frequently filled, and much time is taken to complete the feeding. The 
lid of the brooder, also, should not be kept open for a longer time than is 
unavoidable. 

I have lately made use of a device suggested by Dr. Breck, who first 
brought it to my notice when I was seeing a premature 
infant Avith him in consultation where there was much diffi- 
culty in getting the infant to swallow, and where it would 
not suck. 

It is simply this glass cylinder (Fig. 82), 12 cm. (4f 
inches) long and 2.4 cm. (1 inch) in diameter. The cylinder 
is graduated to 2 c.c. (J drachm), and holds 36 c.c. (9 
drachms). It is shaped at one end so as to have a small 
rubber nipple fitted to it. The large end is covered by a 
rubber cot. The rubber cot, which has no holes, acts as an 
air-reservoir, and by simply introducing the small perfo- 
rated nipple into the mouth and gently pressing the rubber 
cot the food is slowly forced down the infant's throat, 
without choking it and without the infant having to suck 
or apparently to use any effort. To fill the tube the rub- 
ber nipple and cot are removed, a rubber stopper like this 
(Fig. 82) plugs the small end of the cylinder, and the 
required amount of food is poiu'ed in at the large end. 

This method of feeding is especially desirable for a 
weak premature infant in a brooder, because it entails no 
loss of strength on the part of the infant, and can be 
easily managed by the right hand of the nurse while her 
left hand supports the infant's head. This method is 
far preferable to that of gavage, which is not so easily 
managed by the nurse and causes more exhaustion to the 
infant. 

The question is often asked wliether premature infants, 
even if their lives are saved, can be as well developed 
physically and mentally as are those born at term. In my experience, there 
seems to be no question that when once we have succeeded in making the 




— li 



Feeder for prema- 
ture infants (reduced 
one-half). 



314 



PEDIATRICS. 



infant gain steadily in weight and assume the appearance of an infant at 
term its subsequent condition differs in no respect from that of infants born 
at term. 

I have here to show you a picture of the infant (Case 110, p. 307) 
which was treated in Dr. Worcester's incubator. 



Fig. 83. 




Infant premature at thirty weeks. Birth-weight, 2040 grammes. 
Present age, nine months. Present weight, 8400 grammes. 



Treated in incubator eight weeks. 



This picture was taken when the infant was nine months old, and it weighed at that 
time 8400 grammes (17^ pounds). As its birth-weight was 2040 grammes (about 4|- 
pounds), you see that it has quadrupled its weight. It was fed entirely on modified milk 
from the Laboratory during the first year, and is now a fine large boy, walking and talking 
at two years of age. It is perfectly healthy and well developed both physically and men- 
tally. 

His sister, who was premature at the twenty-eighth week, is now eight years old. She 
is well developed and strong, and is unusually bright and intelligent for her age. She is, in 
fact, decidedly in advance mentally of the other children of her age at her school. 



I have here the record of an infant prematurely born at about the 
thirtieth week, and weighing 2850 grammes (about 5 pounds 15 ounces), 
which was the first premature infant that happened to be treated in this 
brooder (Fig. 83). 



PREMATURE INFANTS. 315 

This infant (Case 111) was born at ten minutes past three on February 16. It was 
placed in the brooder at 9 p.m. of the same day, the temperature of the brooder being 
34.4° C. (94° F.). 

On the following day, February 17, the infant was given by the nurse 4 c.c. (1 
drachm) of diluted cow's milk every hour for three feedings, which he vomited almost im- 
mediately after taking. The intervals of feeding were then increased to two hours, but 
the milk was not retained. The nurse then gave him 2 c.c. (J drachm) every three hours 
during the night, which he retained for a number of feedings, but then vomited bile 
and mucus, together with the undigested food which had been given him. 

February 18 the infant was found to have lost 420 grammes (14 ounces) in weight, to 
be very weak, and to be unable to retain the milk diluted with water. The meconium came 
away on this day, and there was a uric acid stain on the napkins. The infant was very 
restless. Its respirations were irregular, and its feet and hands were cold. The tempera- 
ture of the brooder, which up to this time had been kept at 34.4° C. (94° F.), was lowered to 
33.8° C. (93° F.), as the infant had begun to perspire. A substitute food was ordered from 
the Milk-Laboratory on this day, the prescription for which was as follows (Prescription 36) : 

PnESCRiPTioisr 36. 

R Fat 1.00 

Sugar 3.00 

Proteids , 0.50 

To be heated for thirty minutes at 75° C. (167° F.). 

Lime water 5.00 

24 tubes, each containing 4 c.c. (1 drachm). 

This food was given to the infant every hour. 

On the following day, the 19th, the record was that the food had been retained, that 
the infant had seemed so hungry that the amount had to be increased to 10 c.c. (2j 
drachms) , and that it was found advisable to feed it every two hours rather than every 
hour. There was no vomiting. There were two movements of the bowels, which still 
showed evidences of undigested milk and some meconium. The infant's weight on this 
day was found to be the same as on the previous day, 2300 grammes (5 pounds 1 ounce). 

On the following day, February 20, the infant was found to have gained 30 grammes 
(1 ounce). It was taking its food regularly every two hours, alternating with the mother's 
milk, which had come in considerable quantity. There were still evidences of uric acid in 
the urine. The temperature of the brooder was kept at 31.6° C. (89° F.). 

On the following day, February 21, the weight was as on the previous day, 2230 
grammes (5 pounds 2 ounces). The color of the fascal discharges was yellowish brown. 
There was only one discharge in the twenty-four hours, obtained by the use of a supposi- 
tory. The temperature of the brooder was kept at 30° C. (86° F.). 

On the following day, February 22, it was found that the infant had lost 60 grammes 
(2 ounces). The substitute food was then given everj' two hours, alternating with the 
breast-milk. On that day there were three yellow well-digested movements. The tem- 
perature of the brooder was kept at 29.4° C. (85° F.). The infant seemed stronger, was 
very quiet, and slept except when it awoke to receive its food. 

On the following day, February 23, there is no record of the infant's weight, but it 
was evidently in a very precarious condition and seemed exhausted. It did not take its 
nourishment readily. It had five small faecal discharges in the twenty-four hours, which, 
however, were yellow and fairly digested. 

On the following day, February 24, the breast-milk was omitted, and 4 c.c. (1 drachm) 
of modified milk were given every two hours, the percentage of the sugar being raised from 
3 to 3.5. There were four small faecal movements during the day ; the first one was green, 
the last three were yellow and decidedly better digested. The temperature of the brooder 
was kept at 29.4° C. (85° F.). During the day the infant gained 60 grammes (2 ounces) 
in weight. It was so weak on these two days that it would have been dangerous to 
take it out of the brooder to weigh it, so that the continual record of the weight which 



316 PEDIATKICS. 

could be obtained by the scale-bed of the brooder was of the utmost value in regulating 
the changes in the food necessary to save the infant's life. 

On the following day, February 25, the infant's weight was found to be 2260 grammes 
(5 pounds 3 ounces), an increase of 30 grammes (1 ounce). The percentages in the modi- 
fied milk were then changed to the following (Prescription 37) : 

Prescription 37. 

R Fat 1.50 

Sugar 4.00 

Proteids 0.75 

One drop of brandy was given with each feeding. There was one faecal discharge, 
which was yellow and well digested. On this day 4 c.c. (1 drachm) of food were given to 
the infant every two hours until its feeding at 10.30 p.m. After this it seemed so hungry 
that at midnight 36 c.c. (9 drachms) were given, at 3 a.m. 40 c.c. (10 drachms) were given, 
and at 5.30 a.m. 30 grammes (1 ounce) were given. The weight was now found to be 
2420 grammes (5 pounds 5 ounces), an increase of 60 grammes (2 ounces) in the twenty- 
four hours. The amount of food which the infant had taken in the previous twenty-four 
hours was found to have been 375 grammes (12J ounces). The fsecal discharges were 
yellow and well digested. Brandy was continued to be given. The temperature of the 
brooder was kept at 29.4° C. (85° F.). At times a little breast-milk was given to the infant, 
in order to satisfy the mother, but it evidently* did not agree with it. 

On February 27 the weight was found to be 2450 grammes (5 pounds 6 ounces). The 
prescription for the* modified milk was then changed as follows (Prescription 38) : 

Prescription 38. 

R Fat ... 2.00 

Sugar 5.00 

Proteids ' 0.75 

30 grammes (1 ounce) of this were given to the infant every two hours during the 
day, and every two and one-half hours during the night. One yellow well-digested fsecal 
discharge was obtained by means of a suppository. The temperature of the brooder was 
then reduced to 27.7° C. (82° F.). 

The following day, February 28, the weight was found to be 2480 grammes (5 pounds 
7 ounces). The brandy was still continued, and there was one yellow well-digested faecal 
discharge. The breast-milk had been entirely omitted, and 450 grammes (15 ounces) of 
modified milk had been taken in the twenty-four hours. 

On the following day, March 1, it weighed 2510 grammes (5 pounds 8 ounces). The 
amount of modified milk given was 495 grammes (16^ ounces) in the twenty-four hours, 
and one drop of brandy was given with each feeding. There was great improvement in 
the infant's appearance, and it was much stronger. 

On the following day, March 2, there had been no increase or loss in weight. The 
temperature of the brooder was kept at 27.2° C. (81° F.). 510 grammes (17 ounces) of 
the modified milk were taken in the twenty-four hours. There was one fsecal movement, 
well digested and yellow. 

On the following day, March 3, the weight was found to have increased to 2600 
grammes (5 pounds 11 ounces). The percentages of the modified milk were then changed 
to the following (Prescription 39) : 

Prescription 39. 

R Fat 2.50 

Sugar 5.00 

Proteids 1.00 

There were two well-digested faecal discharges on this day. The temperature of the 
incubator was reduced to 25° C. (77° F.). 615 grammes (20^ ounces) of the modified milk 
were given in the twenty-four hours. 



PREMATURE INFANTS. 317 

The following day, March 4, the infant was found to have lost 60 grammes (2 ounces), 
and the temperature of the brooder was therefore raised to 26.6° C. (80° P.). 630 grammes 
(21 ounces) of modified milk were taken in the twenty-four hours, and there was no espe- 
cial change in the infant's condition. 

On the following day, March 5, 30 grammes (1 ounce) in weight were found to have 
been gained, and the infant was looking better and decidedly gaining in strength. It was 
evident that the proper temperature for this especial infant at this age and at this period of 
its development was 26.6° C. (80° ¥.). 

After this time the infant continued to develop normally, and on being taken out of 
the brooder in April was thriving in every way. 

It is now five months old, and weighs 7110 grammes (14 pounds and 13 ounces). 



DIVISION VI. 

GENERAL PRINCIPLES OF EXAMINATION AND 

TREATMENT. 



IvECTURE: XIII. 

METHOD OF EXAMINING A SICK CHILD.— DRUGS. 

Before beginning in detail the actual study of the various classes of 
disease which I shall later present to you for examination, I should like to 
have you understand a few of the general principles a knowledge of which 
I consider of importance in dealing with sick children. 

When a physician is called to see a sick child, he must, if possible, 
ascertain before entering the nursery what is the temperament of the child 
with whom he will have to deal, and by the aid of this information regu- 
late the manner in which he approaches it. 

An infant in the early months of life too young to fear a stranger, a 
child of quiet phlegmatic temperament, or one that is too sick to object to 
being handled, can be examined as soon as it is seen, with the regularity 
and precision which one would employ with the adult. 

It is an entirely different task, however, when one is called upon to ex- 
amine children who are nervous, excitable, or timid, or who are spoiled 
and vicious. In dealing with the first and more difficult class of these cases 
much deliberation in the way in which you approach the child is needed, 
and much diplomacy in speaking to it is indicated. In the second, the 
spoiled and vicious class, you will not gain time by delaying the exami- 
nation, and the sooner you have made it with firmness and persistence 
the less trying it will be for the child and for the mother. As a rule, the 
more the child cries and resists needlessly, the less likely is it to have any 
disease of serious import. 

You will find that it is wise at first to make the child think that 
you are not taking any notice of it, and that you are not even aware of 
its presence. It is well to notice its toys, and to appear to take great 
interest in them and also in the pictures in the nursery. The child very 
soon will become accustomed to your presence, and will begin to take the 
318 



GENERAL PRIXCIPLES OF EXAMINATION AND TREATMENT. 319 

same interest in von that you seem to take in its toys. A nervous, timid 
child will often from this point of the examination allow you to examine 
it without further trouble. 

The physician, however, must always be gentle both in his voice and in 
his touch, and on the slightest appearance of timidity, or manifestation of a 
desire to avoid him, he must at once stop the special part of the examination 
which he is making, and devote himself again to the child's toys. 

All these preliminaries and minute details, which seemingly delay 
the examination, hi fact expedite it, since when once the timid child is 
thoroughly frightened, the rest of the examination becomes very unsatisfac- 
tory, for it is almost cruel in cases of this kind to attempt to force an 
examination, which in the case of the vicious child can be done usually with- 
out this feeling of cruelty and without hurting the feelings of the mother. 

You should acquu-e the faculty of examining the child when it is crying 
and excited with the same precision as when it is quiescent, though perhaps 
by a somewhat different method. The trained hand and ear can detect an 
abdomiaal or pleuritic effusion or a solidified lung almost as well when the 
child is screaming as when it is perfectly docile. 

This is an accomplishment which should be mastered at once by every 
practitioner who expects to have children under his care. In fact, if this 
were more universally understood, we should hear less of the impossibility of 
determining what is the matter with a child on account of its being fractious. 

As the physical examuiation of a child is somewhat more difficult than 
that of the adult, and requires to be made more quickly, you should make 
use of every means at your command which will tend to throw light on the 
final result. 

HISTORY. — A complete history of the case is very valuable, and 
should be obtained from the mother and the nurse, preferably before seeing 
the child, for in this way the physician can obviate asking many questions 
in its presence, a procedure which frequently fatigues it and renders it more 
difficult to examine. It is well to allow the mother and the nurse to 
tell you in their own language what they know about the child and its 
sickness. After they have finished, you can easily systematize the history 
of the case by any questions which you may Avish to ask. Although the 
history given by the mother and the nurse is usually imperfect and discon- 
nected, yet it is very likely to supply certain important points which you in 
your questions might easily overlook. The mother and the nurse are so 
constantly with the child that they notice all the slight shades of difference 
in its condition from hour to hour, a knowledge of which is of great impor- 
tance in obtaining a correct appreciation of the general condition of the 
child, whatever the disease may be. 

Having now systematized in his own mind the history of the case, the 
physician on entering the nursery should proceed with his inspection of the 
child. I am supposing that the child is in one of the two classes which I 
have mentioned as being especially necessary to manage with diplomacy. 



320 PEDIATEICS. 

TEMPERATURE. — Of course it is so important to ascertain what the 
temperature of the child is that, if possible, the temperature should be taken 
before the child has become frightened or fractious. The place for taking 
the temperature in these cases is usually in the axilla. You will find that 
the most successful method of obtaining the temperature under these cir- 
cumstances is to explain to the mother and nurse exactly what you wish to 
have done. You should direct them to take the thermometer and show it 
to the child as though it were a toy, to put it under the child's arm, and to 
play with the child until you tell them to remove the thermometer. 

INSPECTION. — One of the most valuable means of making a diag- 
nosis of disease in children is the careful inspection of the child before 
attempting to percuss or to auscult it. In fact, where children are irritable 
and restless the inspection becomes of the utmost importance, and an eye 
which has been trained to understand the different aspects of disease in 
children readily makes the diagnosis in many cases without further assist- 
ance. A rule to be remembered, and one which you will find of great 
practical value, is, if possible, to have the child entirely undressed, so that 
you can see the whole surface of its skin in front and behind. Not only 
will you thus be able to recognize the symptoms attributable to a simple 
irritation of the skin, where otherwise you might be led to consider them as 
representing a more general and constitutional disturbance, but you will 
also find the skin to be a valuable index by which you can judge of dis- 
eases of the other organs. The cyanosis which so frequently represents 
some disturbance in the heart or lung, the quick respirations of either a 
thoracic or an abdominal type, a sunken or a distended abdomen, and the 
position of the child, all point towards symptoms belonging to special dis- 
eases. By means of all these symptoms, which we can see at a glance, the 
diagnosis of the special disease can usually be made without much aid 
from other sources. 

RESPIRATION. — Either when the thermometer is under the child's 
arm or when you are beginning your regular inspection you can usually 
determine the rate and rhythm of the respiration. Having determined the 
temperature and respiration, if you have seen all that is necessary about the 
child when it is quiescent, you can proceed with the remaining part of your 
examination. 

PALPATION. — Palpation is a very valuable means of diagnosticating 
disease in children, whether it be of the abdomen or of the thorax. It is 
well to begin with an attempt to take the pulse. Sometimes this can be 
readily accomplished. At other times it is impossible ; and, as a rule, I 
rely less on the rapidity of the pulse in the child than on the information 
which is received from the temperature and respiration. It takes so little to 
increase the rate of the pulse in a young child that if we were to judge in 
every case by it we should often be misled in our diagnosis. What we 
wish especially to learn is whether there is a slow pulse or whether it inter- 
mits. This we can usually ascertain by keeping our finger for even only 



GENERAL PRINCIPLES OF EXAMINATION AND TREATMENT. 321 

two or three seconds on the child's radial artery. When we have once 
obtained a fair idea of the rate and rhythm of the pulse we can proceed 
with the remainder of our examination by palpation. 

A young child's thoracic walls are so thin, and vibration is so pro- 
nounced in them, that often we can detect what process is going on in the 
lung by merely putting our hand on the chest, and we can feel in a chronic 
bronchitis what will prove on auscultation to be coarse sonorous rales. We 
can also sometimes feel a pleuritic or a pericardial friction-rub, and fre- 
quently a roughening of one of the valves of the heart. It is not altogether 
impossible in certain cases to distinguish the difference presented to the hand 
between a pleuritic effusion and a solidified lung. The examination of the 
abdomen, even when the child is crying, can be accomplished with consider- 
able precision. Waiting until the child stops crying for a second and 
relaxes its abdominal walls, you can, by firm but gentle pressure, so depress 
the abdominal walls as to obtain a fair knowledge of whether you have an 
abdominal tumor to deal with. You can also readily detect by palpation 
fluid in the abdominal cavity. 

A rectal examination is often important in infants and young children. 
It can readily be done without hurting the child, and the finger is able to 
reach much further proportionately into the child's pelvis than into that of 
the adult, and very much more can be learned by this method than in adult 
cases. An invagination or an appendicitis can be diagnosticated by the 
combined examination through the rectum and by external pressure where 
external palpation alone has failed to give evidence of disease. 

In the infant the head should be carefully examined in regard to the 
fontanelles. Measurements should be taken of the head and of the thorax. 

At this stage of the examination you will have determined almost always 
what disease is affecting the child, but you should, of course, make use of 
every known method for verifying your diagnosis. You should, therefore, 
endeavor to percuss and auscult the child, but in a somewhat different way 
from that which you would naturally employ with the adult. The louder 
the child cries, the easier is it to obtain evidence through vocal fremitus 
what the disturbance is in the chest. 

PERCUSSION. — Even when the child is crying and resisting, percus- 
sion may be of the greatest importance. Light percussion, as a rule, is 
preferable to the deeper and heavier percussion which is often so valuable in 
the adult. The chest-walls, as I have said, are so resonant that deep per- 
cussion rather masks the process which is directly under the finger by bring- 
ing out sounds from all parts of the chest. Direct percussion with the 
finger I have always found preferable to using any instrument, as in this 
way both palpation and percussion may be combined. Palpatory percus- 
sion in my hands has always proved exceedingly valuable for diagnostic 
purposes. A few light taps over the normal boundaries of the heart and 
lung, which I have described to you in a previous lecture (Lecture IV., 
pages 121, 122, 124), will give you much information, even though you are 

21 



322 PEDIATRICS. 

unable to effect a more extended percussion of the chest. If the child 
is crying, you should watch until it takes its breath. Just as it draws in 
its breath it necessarily stops crying, and at that minute you can get a 
perfectly clear result from your percussion. 

You should be careful not to make your physical examination too pro- 
tracted. Rapidity of motion, both in palpation and in percussion, is very 
important, and you should learn to examine a young child with much 
greater rapidity than is usual or necessary in the case of an adult. You 
will in this way obtain much more information than if you wearied the child 
by continual efforts to make sure that you had not made a mistake in the 
evidence which you have acquired up to this point of the examination. 

The sounds which can be elicited from a young child's chest are so 
varied that it is more difficult to differentiate them than in the adult. If, 
therefore, you allow yourself to hesitate and to doubt, you will not arrive 
at as correct a result in your examination as when you have trained your 
mind to grasp at once the salient points in the special physical examination, 
and to depend somewhat more on the first idea which you form than would 
be wise in the case of an adult. 

AUSCULTATION. — I am accustomed next to auscult the child. A 
word may, perhaps, not be deemed unnecessary in regard to the form of 
stethoscope which I am in the habit of using in examining infants and 
young children. It is, I think, unwise to accustom yourselves to the use 
of one form of stethoscope, as you will often have to examine children at 
times when you have not your stethoscope with you, and yet when it may 
be of the greatest importance that a definite diagnosis of the case should be 
made. I have noticed that children are much more sensitive to the feeling 
of the stethoscope than are adults. In many cases they shrink from it as 
though it hurt them, even when they have not been frightened by the pre- 
vious part of the examination with palpation and percussion. It is, there- 
fore, exceedingly important to make the examination as pleasant to the child 
as possible. I have found that a rubber cup applied to the end of the 
stethoscope serves this purpose well. The feeling of the soft rubber is 
pleasant to the child, and it conveys the sound with almost as much 
clearness as does the hard rubber end of the stethoscope. This rubber cup 
can be applied to any stethoscope, such as this one (Fig. 84), which, how- 
ever, does not convey the sound quite so clearly as does this other stetho- 
scope (Fig. 85), which is of such small calibre that it can easily be intro- 
duced between the ribs of even a young child, and which differentiates the 
sounds much more clearly than is done by any other stethoscope which I 
have seen. 

In my opinion, it is often of great aid in the proper appreciation of the 
sounds which are heard with the stethoscope in infants and in young chil- 
dren, especially when they are crying, to use a stethoscope which does not 
convey the sound so clearly and intensely as do others. We can often in 
this way differentiate a soft cardiac murmur which if a more delicate in- 



GENERAL PRINCIPLES OF EXAMINATION AND TREATMENT. 



323 



strument were used would be entirely obscured by the loud sounds coming 
from the trachea and bronchi of a crying or screaming child. We can, 
also, often distinguish the fine rales of a broncho-pneumonia in contra- 
distinction to the loud coarse rales which tend to obscure the other sounds 
in the chest. For a routine examination, however, and for rapidity in its 
completion in cases where we see that a prolonged auscultation will prove 
to be impossible, the smaller stethoscope (Fig. 85) is best adapted for our 
purpose. 

Fig. 84. 



Fig 85 





Stethoscope. 



stethoscope. 



EXAMINATION OF THE THROAT. — We have now examined the 
child in every way except one, which is an exceedingly important one, the 
omission of which might be productive of errors in diagnosis. This is the 
examination of the throat. I have left the examination of the throat to a 
time when we have practically finished with the general examination of the 
child, because, as a rule, it is the procedure of all others which irritates it, 
and after we have once attempted to examine the throat we shall seldom be 
forgiven by the child at that special visit. Some children will allow you to 
look into their throats without being at all disturbed. As a rule, however, 
it frightens them, and we should use the most gentle and rapid methods for 
accomplishing our purpose. We must not expect to be able to sit down in 



324 



PEDIATRICS. 



front of the child and examine its throat for some minutes^ as is possible 
with adults. We must adopt some definite method by which we can control 
the child and catch a glimpse of the mouth, tongue, and pharynx. The 
more quickly we do this, the less it frightens the child, and it is important 
that we should not make extensive preparations, which it will notice and 
which will indicate what we are going to do. The mothers are often much 
disturbed by seeing the child first frightened with the idea that it is going 
to have a spoon put in its mouth, and then, while screaming and crying, 
forced to the window and compelled to open its mouth. It is far better 
under all circumstances to tell the mother and the nurse what to do, and not 
to go near the child until they are entirely prepared to control its limbs 
and are holding it in a position in which it is practically helpless. It 
frightens the child much less to have it sit in the nurse's lap with its face 
to the window than to examine it on its back. I can illustrate best the 
proper method of examining a child's throat where we expect to meet with 
resistance, by picking out a really vicious child, and one which has been 
made vicious by being spoiled, for in these cases we meet with the greatest 
difficulty, and they are cases where diplomacy, persuasion, and delay are of 
no avail. I happen to have here to-day a child of this kind (Case 112). 

Case 112. 




Clinical examination of throat. 



She is eight years old and well developed, and she will be determined tq resist our 
efforts to examine her throat. My directions for examining the throat of such a child are 
as follows : 

I do not let her see what I am going to examine the throat with, nor do I go near her 
until she is ready to be examined. The nurse is instructed to lead the child to a window, 
place a chair in front of the window, and sit down in it, with her face to the window. She 
then lifts the child into her lap, holding its back upright against her chest, and holds it 
by clasping her arms around its arms. By clasping the child's ankles between her feet 



GENERAL PRINCIPLES OF EXAMINATION AND TREATMENT. 325 

or knees, the nurse can absolutely control its movements. She cannot move her arms or 
her legs, nor can she slip down in the nurse's lap, but she is forced to sit upright. All 
she can do is to move her head. When she is once in this position I place my left hand 
on the top of her head, and thus control the movement of the head. She will, as you see, 
open her mouth, and then, watching me, quickly shut it up again just as I am about to 
put the handle of the spoon in her mouth. I next carefully place the handle of the spoon 
between the child's lips. If necessary, in cases which are very intractable, closing the nos- 
trils will make the child open its mouth to get breath. This is usually not necessary, and 
all that we have to do is patiently, firmly, gently, and persistently to watch our oppor- 
tunity, and take advantage of it when it comes, to introduce the handle of the spoon be- 
tween the teeth, and gradually put it on the tongue. When the end of the handle of the 
spoon touches the soft palate the child will gag, and by steady pressure at this moment on 
the base of the tongue a perfectly clear view of the throat will be obtained, and in this one 
glance you should take in all that is to be seen. 

You will thus successfully accomplish an examination in a few seconds 
which the mother had feared would be prolonged and harrowing. 

I prefer to use a spoon for examining the throat, because in every house- 
hold you have one at your command, and it obviates the use of the same 
instrument in a number of mouths, which is something to be considered in 
children, where infection by the mouth is so common. Of course, for those 
who prefer to use the usual tongue-depressor the danger is reduced to a 
minimum if a careful disinfection of the instrument is made after it is used ; 
but in the case of infants, who should also be examined in an upright posi- 
tion, the spoon is decidedly preferable. This is so because the neck of the 
infant is so short that its chin is in close proximity to its chest, and the 
handle of the tongue-depressor interferes with the proper downward pressure 
of the instrument. The spoon-handle, on the other hand, is exactly the 
shape which is best adapted to the infant's mouth and tongue, and the spoon, 
being comparatively straight, does not encroach upon the thorax when the 
downward pressure is made. 

In regard to the examination of the throat, this part of the child may be 
aifected often, and may be the only source of the symptoms which you will 
be called upon to explain, and yet these symptoms may not be what you 
would expect to find where the trouble is in the throat. Young children 
are so apt not to complain of trouble in the tliroat, and to show merely 
signs of general constitutional disturbance, that the physician is very likely 
to be misled and to overlook the real seat of the disease unless he makes it 
a rule always to examine the throat at his first visit. 

INSPECTION OF THE MOUTH.— It is well when the physician is 
examining the throat of an infant in the first two years of its life, and even 
later if there are any symptoms which point towards the mouth, to examine 
carefully the gums. I need scarcely caution you to wash your hands care- 
fully before introducing your fingers into the mouth. This is in accordance 
with the common rules of cleanliness, and also is required in order that you 
should avoid the introduction of pathogenic organisms into the infant's 
mouth. In examining the gums you can judge whether they are swollen 
or reddened, dry, moist, or hotter than normal, and also at times, as I shall 



326 PEDIATRICS. 

explain to you when speaking of diseases of the mouth in children (Lecture 
XL., page 797), you will in this way be able to decide whether there is a 
condition of the gums which indicates the use of the lancet. 

EXAMINATION OP THE EARS. — One of the most important 
means of rightly interpreting the symptoms of restlessness, of evident pain, 
of heightened temperature, of undue somnolence, as well as a great many 
other symptoms, is the examination of the ears of infants and of young 
children. A slight irritation in the throat may at times cause a conges- 
tion in the vessels of the membrana tympani which may produce all these 
symptoms. 

It is, therefore, very important, unless you are sure that the symptoms 
do not arise from some condition in the ear, that you should examine the ears 
at some time during your visit, choosing that time which seems most favor- 
able in the especial case. I consider a thorough knowledge of the possible 
symptoms which may arise from the ear of the very greatest importance for 
the general practitioner to possess. 

DRUGS. — An important fact to remember in the treatment of infants 
and young children is that drugs play a very insignificant part in the actual 
cure of their diseases. According to my observation, numbers of children are 
being treated by drugs, and yet often, so far as I can see, this time-honored 
means of satisfying parental prejudices is but prolonging the symptoms of 
a disease which, self-limited, has run its course. I do not for a moment 
question the direct benefit obtained from quinine in malaria and mercury in 
syphilis : it is the promiscuous use of drugs in every case of sickness to 
which I am especially opposed, for in many cases the child will recover with 
equal or even greater rapidity without them. 

Instances probably arise in the practice of every physician where he 
feels that the drugs which have been given have either directly harmed tlie 
cliild or, by disturbing its digestion and thus interfering with its nutrition, 
have indirectly produced more serious symptoms than those presented by 
the original disease. The greatest caution should be employed where drugs 
are used with young children, and there should be a thorough understanding 
of their action during the various periods of development. The well-known 
susceptibility of children to the action of opium and its alkaloids should 
make us careful to begin with minimum doses when it is necessary to use 
this drug. In like manner, although it is traditional that children have a 
great tolerance for belladonna and arsenic, we must allow that an overdose 
of the former, although not usually fatal, may certainly produce most 
alarming symptoms, while the administration of the latter as I have seen 
it given in the treatment of chorea has in a number of cases produced a 
multiple neuritis. 

The treatment of diseases by special drugs because these drugs have 
been given in the past, because their administration has apparently done no 
harm, or because no new or better remedy has been found, rests upon a lack 
of comprehension of what treatment really means. 



GENERAL PRIXCIPLES OF EXAMINATION AND TREATMENT. 327 

The custom of combining many drugs in one prescription is fallacious, 
and should be discountenanced, especially where infants and young children 
are being treated. A single drug given in the smallest dose which will 
accomplish its purpose, and in the most agreeable form which is compatible 
with the function of digestion, will produce the best results in any given 
disease. 

The delicate skin of infants and young children is peculiarly sensitive to 
reflex disturbances caused by drugs in the gastro-enteric tract, and there- 
fore we must be careful not to mistake the appearances produced by such 
reflex irritation for the various lesions of the skin which may occur in a 
specific disease. Thus, the similarity of the efi&orescence produced by bella- 
donna to that accompanying scarlet fever is striking. Almost any drug, as 
well as certain articles of diet, may in some individuals produce forms of 
papular erythema, resembling very closely some of the dermal lesions of 
syphilis. It is therefore wise to avoid these possible disturbances of nutri- 
tion by giving drugs only where they are actually known to be necessary, 
and by omitting them as soon as possible. 

It has always seemed to me irrational to prescribe syrups as a men- 
struum for the administration of drugs to children. Their well-known 
tendency to fermentation is sufficient to stamp them as imfit for the treat- 
ment of a period of life when the undeveloped condition of the digestive 
function indicates the vital importance of protecting this function in every 
way. 

Each case must be treated according to its special pathological lesion or 
specific micro-organism. As year by year we are discovering the organisms 
which cause special diseases, so the treatment of the future will be the 
actual destruction and speedy elimination of these organisms while support- 
ing the strength until such elimination has been accomplished. Where no 
known organisms exist, the treatment should be if possible to remove the 
cause, and to support the vitality until natural processes have healed the 
special lesion, produced either by exposure or by trauma. 

In connection with what I have said regarding the unnecessary use of 
drugs in early life, the following case is of considerable significance : 

An infant five months old was reported to me to have tubercular meningitis. The 
history of the case was as follows : 

A healthy breast-fed infant (Case 113), with a healthy mother, had been for two weeks 
showing signs of fretfulness, which, as afterwards proved, were closely connected with irri- 
tation of the two lower middle incisors, which were in the process of coming through the 
gum. The infant had had a slight cold for two days, and on the second day had been more 
restless than usual in the afternoon, and had screamed a great deal. The attending physi- 
cian prescribed a mixture of fifteen drops of tincture of opium in thirt}' teaspoonfuls of 
water, to be given in teaspoonful doses at intervals during the night, if it was found neces- 
sary to quiet the infant. During the night the infant's hands and feet were reported to be 
cold, and by morning it was found to be almost unconscious. The physician at this time 
made the diagnosis of tubercular meningitis, and on the following day, when it was seen by 
me with him, it was found to have contracted pupils, cool skin, a rectal temperature of 37° 
C. (98° F.), a fontanelle somewhat depressed, a regular pulse, 120, and respirations quiet 



328 PEDIATRICS. 

and not especially slow. It did not notice anything, except when it was roused, at which 
time it would cry vigorously, as though it were annoyed at being disturbed. 

On inquiry, it was found that the nurse during the night had given eight teaspoonfuls 
of the mixture which I have just mentioned. This amount must have contained at least 
four drops of tincture of opium. 

A dose of sulphate of atropia of 0. 0003 {^^ of a grain) was given at once by the mouth. 
Four hours later the pupils became less contracted, but were reacting sluggishly. An hour 
later another dose of sulphate of atropia of the same strength was given, and the pupils then 
dilated, the infant grew brighter, and recovered within twenty-four hours. 

After the second dose of atropia had been given, an efflorescence, which probably was 
the result of the physiological action of the atropia on the skin, appeared on the chest and 
face for a few hours, and the skin then became normal. This efflorescence, it is well to 
record, was at first mistaken for that of scarlet fever, so that in the same case an erroneous 
diagnosis of two entirely different diseases was made, and in each case the symptoms sup- 
posed to represent these diseases were really caused by the drugs which had been given to 
the patient. 



DIVISION VII. 

THE BLOOD IN INFANCY AND CHILDHOOD. 



LKCTURE XIV. 

LITERATURE.— NOMENCLATURE.— BLOOD-KEY.— METHODS.— CHEM- 
ISTRY.— ORIGIN.— FCETAL BLOOD.— THE NORMAL CONDITIONS 
OF THE BLOOD IN EARLY LIFE. 

As our knowledge advances regarding the etiology of disease, it is be- 
coming very evident that we should not only direct attention to the pathology 
of the tissues outside of the blood, but should also investigate the varied 
conditions which exist in the blood itself. The blood does not merely absorb 
the waste matter from the tissues and carry fresh oxygenated material to 
replace it. It plays a far greater part in the economy than this, and is inti- 
mately connected with many diseases. 

It is not only in the corpuscular elements of the blood that we find 
various changes corresponding to certain conditions existing in the indi- 
vidual. We must in the future go still further and read what the blood 
serum is waiting to disclose to us. 

Although an immense amount of labor has been expended on examina- 
tions of the blood, both chemical and microscopic, especially in that of 
adults, the present state of our knowledge concerning its diseases, and its 
conditions as representative of other diseases, is very unsatisfactory. 

Our knowledge of the blood in early life is still more meagre than at a later 
period. Although in the last few years the literature of the blood in general 
has become very extensive, yet that pertaining to infancy is small. We must, 
indeed, confess that what we definitely know of the diseases of the blood in 
the first few years of life is wanting in exactness and veiled in obscurity. 

It is exceedingly important, therefore, that the results of individual 
investigation in this class of cases should be published as soon as possible, 
for the purpose of rendering mutual aid in unravelling the mysteries of this 
interesting subject. For many years I have met with cases whicli have been 
difficult to classify beyond their evident connection with the blood. 

During the last two years I have endeavored to formulate more sys- 
tematically my clinical observations on these cases, and I have been enabled 

329 



330 



PEDIATRICS. 



to collect some valuable data for diagnosis and prognosis. In the accom- 
plishment of this work I have received much assistance from Dr. William 
F. Whitney, who has with great patience and labor differentiated the speci- 
mens as they were brought to him from the several cases on slides for 
microscopic examination. I wish especially to direct attention and award 
great merit to Dr. A. H. Wentworth's work. He has labored in this field 
for me unceasingly during the past two years, going to my cases, preparing 
the slides, and estimating the red and white corpuscles and haemoglobin. Up 
to the present time very little work on infants, corresponding to Dr. Went- 
worth's, has been done in this country, and it is therefore especially valuable. 
NOMENCLATURE. — The various terms used to designate the elements 
of the blood will soon become as familiar to the general practitioner as those 
now used in clinical medicine. I think, however, that you may not deem 
it unnecessary for me to explain to you the meaning of some of the words 
which I am about to use. I have endeavored to do this in the following 
table (Table 84), and by means of this colored plate, showing the various 
elements of the blood (Plate V.). 



TABLE 84. 

Meaning of ihe Terms used in Describing the Blood. 
Erythrocytes ...... Normal red corpuscles 



1. Haematoblasts . . 
of Neumann. 

(1) Normoblasts 

(2) Megaloblasts 



(3) Microblasts . . . 

2. Haematoblasts .... 

of Hayem and Bizzo- 
zero. 

3. Microcytes . . . 

4. Macrocytes . . . 

or Megalocytes. 

5. Poikilocytes . . 
Oligocythgemia . 
Haemolysis . . . 
Haemoglobin . . 
Oligochromaemia 
Haemoglobin^mia 
Haemoglobinuria 

Leucocytes .... 

1. Lymphocytes . . 

or small mononuclear. 
(Young (unripe) ele- 
ments of Uskow.) 

2. Large mononuclear . . 

(Mature (ripe) ele- 
ments of Uskow. ) 



Nucleated red corpuscles 



Size of erythrocytes, having a small deeply 
staining nucleus 

Large nucleated red corpuscles, having a 
large, often fragmented, nucleus, staining 
faintly 

Small nucleated red corpuscles. 

Blood plates, supposed by these authors to 
be young red blood-corpuscles. 



Abnormally small erythrocytes 
Abnormally large erythrocytes. 



Abnormally-shaped erythrocytes 

Eeduction in number of erythrocytes. 

Destruction of erythrocytes. 

Coloring matter of the blood. 

Eeduction of hemoglobin. 

Presence of haemoglobin in the serum. 

Presence of haemoglobin in the urine. 

White corpuscles. 

Round mononuclear cells about the size of 
erythrocytes, with faintly staining proto- 
plasm. The nucleus stains deeply, and 
fills nearly the whole cell 

Eully double the diameter of erythrocytes, 
with oval or round faintly-staining nu- 
cleus, filling a relatively small part of the 
cell 



(Plate Y., 5.) 
(Plate v., 6.) 



(Plate Y., 6.) 
(Plate Y., 6a.) 

(Plate Y., 1h.) 
(Plate Y., 7a.) 



(Plate Y., L) 



(Plate Y., 2.) 



Anaemia Infantum Pseudo-Leukaemica von JAKSCI- 






Plasmoidium Malanae 
, Oillmmers.RElCHERTXs 
Ocular N? 3, 



^ 






l^ll^. 



^^^«: p^^ 









5-««^ 



^ 1 * ^ • 



ky 




■.M^"^ 



.^ 



J.B.uppincott Company. 




LEITZOil Immers.>^2 Ocular N°3 



:, Small Mononuclear 
( Lymphocytes.) 

2. Large Mononuclear 

a. Transitional , 

3. Polynuclear Neui 

4. Polynuclear Eos- 

b. Dwarf Eosmor 
: Ncrms' Red Cor" 



MsijalDbiai: ! ,,-: 
Poikiiocytes 

MiuclearNeu 



THE BLOOD IN INFANCY AND CHILDHOOD. 331 



TABLE S4:.— Continued. 

Transitional forms . . Cells like the above, but having an indented 

(Lobulated or indented nucleus (Plate Y., 2a.) 

forms of Uskow.) 

Neutrophiles Considered by most observers the oldest 

or poly nuclear cells variety of the leucocytes. The nucleus 
(more correctly poly- stains with basic stains ; the plasma stains 
morphnuclear. Old faintly with neutral aniline stains, and the 
(over-ripe) elements granules stain with a combination of both 
of Uskow). basic and acid stains, and hence are called 

neutrophiles. The nucleus is really poly- 
morphous, though sometimes (apparently) 

broken (Plate V., 3.) 

Myelocytes. ..... Large, round, or ovoid cells, with one (seldom 

or large mononuclear two) large faintly-staining nuclei. The 
neutrophiles. "Mark- plasma is filled with small granules that 

zellen" of the Ger- take a neutral stain (Plate V., 8a.) 

mans. 

Eosinophiles Characterizedby the presence of large, round, 

highly refractile granules, which stain with 

all acid coloring matters (Plate Y., 4.) 

(a) Polymorphnuclear (Plate Y., 4.) 

(b) Mononuclear (Plate Y., 86.) 

Leucocytosis An increase in the number of leucocytes, 

the increase being in the polymorphnu- 
clear neutrophiles. 

Microcytosis . ... An increase in the number of microcytes. 

Monochromatophilic . Taking only one stain. 

Polj'chromatophilic . . Taking more than one stain. 

Basophilic Stained by basic stains. 

Acidophilic Stained by acid stains. 

or Eosinophilic. 

Neutrophilic Stained by neutral stains. 

Amphophilic Stained by both basic and acid stains. 

Erythroblasts A term used by some authors to describe 

certain very early stages in the develop- 
ment of erythrocytes found only in the 
blood-forming organs, 

Leukoblasts A similar term applied to the early stages in 

the development of leucocytes. 

Mitosis A division of nucleus and cell in which the 

or Karyokinesis. division is preceded by certain definite 

(Indirect cell division.) changes in the arrangement of the mor- 
phological constituents of the nucleus and 
cell. 

Amitosis A simple division of nucleus and cell, not 

(Direct cell division.) accompanied hj previous alteration in the 
constituents of either. 



BLOOD-KEY. — I should like you to examine these colored pictures 
(Plate v., facing page 330), which represent all the principal normal 
and abnormal conditions of the blood in early life. They are, in fact, a 
key which Dr. Wentworth has so arranged that, by first becoming familiar 



332 - PEDIATRICS. 

with the pictures in the plate, and then calculating the percentages from 
your microscopic blood-slides, you will be able to read and understand the 
special case which you are studying. Thus, knowing the special combina- 
tion of the blood-elements which constitute a certain disease, and seeing 
that combination under your microscope, you can easily make the diagnosis 
of the disease. 

This method is, of course, more satisfactory than showing the blood- 
field of any single case ; for what we see is of no particular value until a 
histological computation of the relative percentages of the different elements 
composing the blood has determined the especial combination which repre- 
sents the particular disease. 

I shall now briefly describe to you the general methods by which blood- 
counts are made. For the special technique I must refer you to the 
admirable laboratory courses that are given in another department of the 
school. 

The instrument used for estimating the number of red and white cor- 
puscles is called the Thoma-Zeiss. It consists of two parts, a glass count- 
ing-slide and a mixing-pipette. By pricking the lobule of a carefully 
washed ear a single drop of blood is made to exude. The first drop of 
blood that comes having been wiped away and a second having taken its 
place, the end of the mixing-pipette is brought in contact with it and a por- 
tion is sucked up in the capillary tube, the amount taken being shown on a 
scale. The end of the pipette is then immersed in a diluting fluid, and 
the blood, with either one hundred or two hundred times its volume of 
the diluent, is sucked into the bulb to which the capillary tube enlarges. 
After this the pipette is shaken for at least two minutes to insure the 
even distribution of the corpuscles. For counting the erythrocytes the best 
diluting solution is that known as Toison's, the formula for which is, — 

Prescription 40. 

B Sulphate of sodium 8.000 

Chloride of sodium 1.000 

Glycerin 30.000 

Methyl violet 0.025 

Distilled water 160.000 

Having blown out the first few drops from the pipette, in order to be 
sure of getting a drop that represents a fair average, the next is put in the 
small depression that is made for it in the counting-slide. Around this 
central well is an overflow moat, bounded by a slightly raised glass plate. 
The whole is so constructed that, when the central well is evenly full of 
fluid and sealed over by laying on the cover-glass, its depth is exactly 
one-tenth of a millimetre. On the floor of this well a square millimetre 
has been ruled off into four hundred small squares. The drop of blood, 
just large enough to fill this well, but not to overflow the moat, shut in by 
its cover-glass, is laid aside for two or three minutes, so that the globules 



THE BLOOD IN INFANCY AND CHILDHOOD. 333 

may all fall to the bottom. Then, under the microscope, the number of 
red and white corpuscles lying in a definite number of the small squares 
can readily be counted, and, as each square is just one four-thousandth of a 
cubic millimetre, a very simple multiplication will give us the number of 
corpuscles in a cubic millimetre of the undiluted blood. All blood exami- 
nations are reported in terms of cubic millimetres. In my cases, one 
hundred and sixty small squares were counted in each of four successive 
drops of blood, and the average made up from these. 

Although, owing to the blue color given them by the Toison's solu- 
tion, the leucocytes can be counted at the same time as the erythrocytes, 
yet it is often more convenient to use a solution that, by rendering the 
red cells invisible and emphasizing the nuclei of the whites, will render 
the task of counting the relatively small proportion of white cells easier. 
For my counts a three-tenths of one per cent, solution of acetic acid was 
used, the blood diluted one hundred times, and twenty thousand squares 
counted. 

The haemoglobin percentage is generally determined by means of the 
Fleischl hsemoglobinometer. A fine piece of glass tubing set at right 
angles in a handle is used as the measure for the blood, which is then 
dissolved out in distilled water held in a glass-bottomed cell. The colored 
water is compared by artificial light with a graduated red glass prism, and 
when the exact equivalent is found an index on the instrument shows the 
percentage of haemoglobin. 

The third step in the process is the making of the dried cover-glass 
preparations. This is the one that can be most readily done by the general 
practitioner, and the one that will give him the most information. The 
cover-glasses must first be carefully cleansed with acid and alcohol. One 
of the clean cover-glasses is taken in the forceps and gently touched for a 
moment to a fresh drop of blood as it rests upon the ear ; the second glass 
is then dropped upon the first. If both were perfectly clean, the blood will 
be seen immediately to spread itself out betsveen the two as a delicate film. 
The glasses are at once separated by a sliding motion, and allowed to dry 
in the air. When dry, if protected from dust and moisture, they can be 
kept indefinitely. The next step in the process is to harden them. This 
may be done by soaking them in benzine for ten minutes, or in equal parts 
of ether and absolute alcohol for half an hour; or they may be heated, 
preferably by leaving them for two hours on a metal plate kept just hot 
enough to vaporize a drop of water, but for rough clinical work holding 
them in the fingers for a couple of minutes over the flame of an alcohol 
lamp is sufficient. 

The last step in the process is the staining. To accomplish this a great 
variety of stains have been used, each bringing out some one peculiarity of 
cell-structure with greater distinctness than the others. The cells shown in 
the colored plate (Plate V., facing page 330) were stained with the Ehrlich 
triple stain, which is made as follows : 



334 PEDIATRICS. 

Prescription 41, 

R Saturated watery solution of orange G 125 c.c. 

Saturated watery solution of acid fuchsine (containing 20 per cent. 

alcohol) 125 c.c. 

To this are added slowly, while constantly shaking the mixture, a 

Saturated watery solution of methyl green 125 c.c. 

Absolute alcohol 75 c.c. 

This stains the nuclei of the leucocytes a blue or bluish-green color, the 
neutrophilic granules a purple, and the eosinophilic granules a reddish 
tinge. The erythrocytes are stained a faint yellow. According to the 
amount of heating the cover-glasses have had, they are left in the staining 
fluid from one to four minutes, and then washed in plain water and dried. 
Finally, mounted in cedar oil or Canada balsam, they are ready for exam- 
ination with the oil -immersion objective. 

Of these various procedures the estimation of the haemoglobin per- 
centage must be done at once. The mixing-pipette, having been filled and 
shaken, can safely be left from twelve to fourteen hours or even longer 
without any change taking place in the corpuscles that will interfere with 
their being counted. The cover-glass films can, as I have already told you, 
be kept indefinitely. 

CHEMISTRY. — The chemistry of the blood in early life has not yet 
been fully investigated. It may, however, be of interest to you to have a 
general idea of this fluid medium which we are about to study in health 
and in disease as it exists in the adult. In this way you will be better pre- 
pared to understand the more intricate pathological questions which must 
be dealt with later. This general idea can best be acquired by directing 
our attention to the chemistry of the blood. 

The chief chemical facts which are known concerning the blood have 
been so lucidly stated by Foster that I can best assist you by quoting from 
what he says on the subject. Foster states that the average specific gravity 
of human blood is 1055, varying from 1045 to 1075 w^ithin the limits of 
health. The reaction of the blood as it flows from the blood-vessels is 
found to be distinctly, though feebly, alkaline. If a drop be placed on 
a piece of faintly red highly glazed litmus paper and then wiped ofi", a blue 
stain will be left. 

The whole blood contains a certain quantity of gases, such as oxygen, 
carbonic acid, and nitrogen, which are held in the blood in a peculiar way, 
and which vary in venous and in arterial blood, and so serve especially to dis- 
tinguish them from each other. These may be given off" from the blood when 
exposed to an atmosphere, according to the composition of that atmosphere. 

The normal blood consists of corpuscles and plasma. If the corpuscles 
be supposed to retain the amount of water proper to them, blood may, in 
general terms, be considered as consisting by weight of from one-third to 
somewhat less than one-half of corpuscles, the rest being plasma. The 
plasma is resolved by the clotting of the blood into serum and fibrin. 



THE BLOOD IN INFANCY AND CHILDHOOD. 335 

The serum contains, in 100 parts, — 

Proteid substances about 8 or 9 parts. 

Fats, various extractives, and saline matters about 1 or 2 parts. 

Water about 90 parts. 

The proteids are paraglobulin and serum-albumin in varying propor- 
tions, there being probably more than one kind of serum-albumin. AVe 
may perhaps say that they occur in about equal quantities. 

The fats, which are scanty, except after a meal or in certain patho- 
logical conditions, consist of the neutral fats, stearin, palmitin, and olein, 
with a certain quantity of their respective alkaline soaps. The comi3lex 
fat lecithin occurs only in very small quantities. The amount present of 
the peculiar alcohol cholesterin, which has so fatty an appearance, is also 
small. Among the extractives present in serum may be put down nearly 
all the nitrogenous and other substances which form the extractives of the 
body and of food, such as urea, kreatin, sugar, and lactic acid. A very 
large number of these have been discovered in the blood under various 
circumstances, the consideration of which must be left for the present. 
The odor of blood or of serum is probably due to the presence of vola- 
tile bodies of the fatty acid series. The faint yellow color of serum is due 
to a special yellow pigment. The most characteristic and important chemi- 
cal feature of the saline constitution of the serum is the predominance, at 
least in man and in most animals, of sodium salts over those of potassium. 
In this respect the serum offers a marked contrast to the corpuscles. Less 
marked, but still striking, are the abundance of chlorides and the poverty of 
phosphates in the serum as compared with the corpuscles. The salts may, 
in fact, briefly be described as consisting chiefly of sodium chloride, with 
some amount of sodium carbonate — or, more correctly, sodium bicarbonate 
— and potassium chloride, with small quantities of sodium sulphate, sodium 
phosphate, calcium phosphate, and magnesium phosphate. Of even the small 
quantities of phosphates found in the ash, part of the phosphorus exists in 
the serum itself, not as a phosphate, but as phosphorus in some organic body. 

The red corpuscles contain less water than the serum, the amount of 
solid matter being variously estimated at from 30 to 40 per cent, or more. 
The solids are almost entirely organic matter, the inorganic salts amounting 
to less than 1 per cent. 

The red coloring matter which in normal conditions is associated with 
this stroma may by appropriate means be isolated, and in the case of the 
blood of many animals obtained in a crystalline form. It is callwi hanno- 
glohin, and may by proper methods be split up into a proteid belonging to 
the globulin group, and into a colored pigment, containing iron, called 
hcBmatin. Haemoglobin is therefore a very complex body. It is found to 
have remarkable relations to oxygen, and indeed the red corpuscles by 
virtue of their haemoglobin have a special Avork in respiration, for they 
carry oxygen from the lungs to the several tissues. 



336 PEDIATRICS. 

Of the organic matter, again, by far the larger part consists of haemo- 
globin. In 100 parts of the dried organic matter of the corpuscles of 
human blood about 90 parts are haemoglobin, about 8 parts are proteid sub- 
stances, and about 2 parts are other substances. Of these other substances 
one of the most important, forming about a quarter of them and apparently 
being always present, is lecithin. Cholesterin appears also to be normally 
present. The proteid substances which form the stroma of the red cor- 
puscles appear to belong chiefly to the globulin family. As regards the 
inorganic constituents, the corpuscles are distinguished by the relative 
abundance of the salts of potassium and of phosphates. This at least is 
the case in man. The relative quantities of sodium and potassium in the 
corpuscles and serum respectively appear, however, to vary in different 
animals ; in some the sodium salts are in excess, even in the corpuscles. 

The proteid matrix of the white corpuscles is composed of myosin, or 
an allied body, paraglobulin, and possibly other proteids. The nuclei con- 
tain nuclein. The white corpuscles are found to contain, in addition to pro- 
teid material, lecithin and other fats, glycogen, extractives, and inorganic 
salts, there being in the ash, as in that of the red corpuscles, a preponder- 
ance of potassium salts and of phosphates. 

The main facts of interest, then, in the chemical composition of the 
blood are as follows. The red corpuscles consist chiefly of haemoglobin. 
The organic solids of the serum consist partly of serum-albumin and partly 
of paraglobulin. The serum or plasma contrasts in man, at least, with the 
corpuscles, inasmuch as the former contains chiefly chlorides and sodium 
salts, while the latter are richer in phosphates and potassium salts. The 
extractives of the blood are remarkable rather for their number and varia- 
bility than for their abundance, the most constant and important being 
perhaps urea, kreatin, sugar, and lactic acid. 

ORIGIN. — According to Ziegler, the regeneration of the colorless blood- 
corpuscles takes place principally in the lymphadenoid tissues of the 
lymph-glands, the spleen, and the intestinal tract. The lymph-bulbs con- 
tain regions, sharply differentiated from the surrounding tissue, in which 
are always to be found stellate figures which for the most part belong to 
free cells. These regions are called by Flemming ^^germ-centres.'' In 
addition to this, a division of leucocytes takes place in the lymph-channels 
of the lymph-glands and other tissues, and there can be little doubt that 
leucocytes also divide while circulating in the blood or wandering among 
the tissue-clefts. 

This division may be either by mitosis, which gives cells with pecu- 
liarly lobate or crown-like nuclei, or by amitosis, in which case the nucleus 
appears broken into fragments. 

The mitotic division is that which leads to the formation of vigorous 
cells. To what extent the amitotic division — that is, the breaking down of 
the nucleus — is also followed by cell division is diflicult to determine, but it 
is probably true that this represents the result of a process of destruction, 



THE BLOOD IN INFANCY AND CHILDHOOD. 337 

and that the change from mononuclear to polynuclear cells should therefore 
be looked upon as a degeneration. Frequently under pathological conditions 
there occurs an increase in leucocyte-formation. 

Since in leucaemia the spleen, the lymph-glands, or the bone-marrow 
show a hypertrophic condition with increased cell-production, it may be 
supposed that they furnish the increase of leucocytes to the blood. The 
regeneration of the red blood-corpuscles occurs probably by mitotic division 
of the red nucleated young forms. In adults this division takes place only 
in the bone-marrow, which is true also of mammals, birds, reptiles, and the 
tailless amphibise; in the tailed amphibise and in fishes it can occur in 
the spleen as well. In the embryo this process can go on in the entire 
vascular system. Later it becomes concentrated in the liver, spleen, and 
bone-marrow, and finally becomes restricted, according to our present 
knowledge, to the marrow alone. Where these nucleated young forms 
originate is still a matter of dispute, some investigators considering that 
they are the direct descendants of the young forms of embryonic life and 
that they have always held haemoglobin, others maintaining that they are 
developed from pre-existing nucleated forms without haemoglobin, which in 
their turn are said by some to multiply in the vessels of the marrow, and 
by others to originate also in the spleen. 

Neumann believes that there either occurs a development of the nucle- 
ated blood-corpuscles out of the leucocytes of the blood which after birth 
are conveyed through the arteries to the bone-marrow, or that they spring 
from the tissue elements of the bone-marrow. 

Fate of the Red Corpuscles. — About the length of life and the 
ultimate fate of the red corpuscles little is known. Osier points out 
that the bile coloring matters and certain of the urinary pigments have 
their origin in altered haemoglobin, which would require the daily destruc- 
tion of many red blood-corpuscles. So far as we can see, these corpuscles 
are removed without undergoing much alteration. Certain evidence, how- 
ever, seems to point to the spleen and liver as organs in which they 
are broken up, and in which they are perhaps used again in making the new 
corpuscles. 

FCETAL BLOOD. — In accordance with the fact that the younger the 
individual the more unformed, or rather unripe and undeveloped, are the 
elements of the blood, certain stages of the corpuscular development being 
transmitted directly from the foetal conditions, it will be wise to speak first 
of the character of the blood in intra-uteriue life. Taking these conditions 
as a starting-point and using the adult blood for comparison, we can obtain 
a fairly comprehensive understanding of the various conditions which are 
known to be present in the blood of infants and children. 

According to Scherenziss, the specific gravity of the foetal blood at the 
moment of birth is somewhat lower than that of the adult's. That of the 
serum is markedly lower. The red corpuscles are poor in haemoglobin and 
rich in stroma. Compared with the adult, the haemoglobin is as 76.8 to 100. 

22 



338 PEDIATRICS. 

The amount of fibrinogen is relatively small, and as compared with the 
mother's blood is as 2 to 7. 

Foetal blood is not well qualified for the method of quantitative analysis 
by means of washing with salt solution, because many of the elements 
which are loosely held in the red corpuscles, especially the haemoglobin, 
are easily washed out. 

The foetal blood is somewhat richer in sodium and considerably poorer 
in potassium than is adult blood. The amount of chlorine not combined 
with sodium and potassium is much less than in adult blood. The sex and 
weight of the child at the moment of birth do not appear to have any 
influence upon the quantitative composition of the blood. 

Some authors have thought that they found a lessened tendency to coag- 
ulation in the blood of the new-born. Kriiger found that this tendency 
existed in the sense that the coagulation occurred slowly. He thought that 
this was due to the diminished tendency of the leucocytes to undergo retro- 
grade changes. He also found more iron in the blood at birth than after a 
lapse of fourteen days. 

Erythrocytes. — Normally, the red corpuscles in the foetal blood are 
nucleated, at least in the early months ; they are of the normoblast type 
(Plate v., 6, facing page 330). After the seventh month they diminish 
rapidly in number, and give place to the normal red corpuscle. There 
is some difference of opinion as to the frequency of the occurrence of the 
normoblasts in the last few months of intra-uterine life, but the best 
observers seem to agree that they are rather infrequent. 

Leucocytes. — Fischl, in a report of four cases, found up to the end 
of the seventh month very few eosinophiles, after this a large number, and 
then a diminution towards the end of full term ; and the observations of 
Weiss agree with this. He found little variation in form and in size. There 
is a low percentage of lymphocytes up to the seventh month, the majority 
of the corpuscles consisting of the large mononuclear cells (Plate V., 2). 
After the seventh month, an increase of the former and a diminution of the 
latter occur as full term is approached. The transitional variety (Plate V., 
2a) predominates at birth, and later gives place to the polynuclear (Plate 
v., 3 and 4, facing page 330). 

Gundobin found that in the blood of premature infants the lymphocytes 
(Plate v., 1) were both relatively and absolutely increased, and that it was 
therefore a younger blood. He found also that the same changes occur in 
the leucocytes of the premature infant's blood as in that of the infant at 
full term, only that there is a more rapid diminution up to the third or 
fourth day, and that the leucocytes remain below the average a longer time, 
from ten days to three weeks, than they do in the blood at full term. 
When the development of the infant was slow, its blood was correspondingly 
slow in development, its red corpuscles were diminished, its haemoglobin 
was diminished, there was an increase of leucocytes, and in this way a con- 
dition of anaemia with leucocytosis was produced. 



THE BLOOD IN INFANCY AND CHILDHOOD. 339 

Just as I have explained to you that to understand intelligently the 
diseased conditions of early life you must first acquire a knowledge of the 
normal development of the infant and child during the different periods of 
their existence, so I wish to impress upon you the importance of knowing 
what exists normally in the blood of early life before you can appreciate 
the abnormal conditions. I shall therefore first describe what is found in 
the normal infant's and child's blood, comparing it with the adult's blood, 
and then point out the variations caused by disease. 

NORMAL BLOOD AT BIRTH.— Amount.— Welcker states that the 
total amount of blood at birth is one-nineteenth of the body-weight. His 
opinion is based on the examination of a poorly developed infant, in which 
the umbilical cord was ligatured immediately at birth. 

Schuecking places the amount at one-fifteenth of the body-weight, from 
an examination of five full-term infants, without expressing the blood 
from the placenta, and with immediate ligature of the cord. When the 
cord was tied later, and the so-called '^ reserve" blood was expressed from 
the placenta, the percentage rose to one-ninth. In adults the relation of 
the blood to the body-weight is stated to be one-thirteenth. All authors 
agree that there is a temporary gain in the amount of the blood when the 
cord is tied late. 

Reaction. — The reaction of the blood at birth is always alkaline. 

Color. — The color is found to be darker in the capillaries during the 
first few days than at any other time. 

Specific Gravity. — At birth the specific gravity of the blood is about 
1065, and this does not vary for the first few weeks. From this time up to 
the second year there is a constant diminution, decreasing in boys to as low 
as 1048 and in girls to 1050. It then gradually rises, till at the end of the 
first year it has reached the normal average of 1050 to 1058. The specific 
gravity seems to be uninfluenced by the number of red or white corpuscles, 
food, rest, exercise, or other causes, but depends directly upon the amount 
of haemoglobin. As a whole, the specific gravity is, apart from physio- 
logical variations, very constant in the same individual, and remains for 
weeks and months the same. Hock and Schlesinger place the greatest^ 
twenty-four-hour variation at 0.00025. Let me here remind you that the 
appearance of the child's skin is not an index to the specific gravity of the 
blood or to the amount of the haemoglobin. Children often appear anaemic 
without any especial alteration in either of these conditions. 

Specific Gravity of the Blood-Serum. — Hock and Schlesinger's 
results are the most reliable. They estimated the specific gravity by a 
method of Hammerschlag's which has not yet been published. They 
found in young children that the physiological variations were much greater 
than in adults, and w^ere often between 1026 and 1031. Adults, on the 
other hand, according to Hammerschlag, showed very little variation, per- 
haps from 1029 to 1031. Older children resemble adults. The deductions 
from these investigations seem to be, that any marked change in the specific 



340 PEDIATEICS. 

gravity either of the blood or of the seram^ aside from the action of drugs 
on the haemoglobin, denotes a marked change in the whole organism and in 
the functions of the various organs. 

HEMOGLOBIN. — The haemoglobin is found to be less firmly bound to 
the red corpuscle in the infant at term than it is in adults. It is, however, 
proportionately greater at birth than in adult life. The haemoglobin, like 
the specific gravity, which, as I have told you, seems to be dependent upon 
it, reaches its maximum at birth. Starting at 100 or 104, it falls rapidly to 
its minimum in the first three weeks of life. (Hock, Schlesinger, Widowitz, 
Schmaltz, and Hammerschlag.) The lowest percentage that you will find 
varies from 55 to 96.5 per cent. From two weeks to six months it remains 
about the same, and then rises slowly. 

Erythrocytes (Plate V., 5, facing page 330). — So far we have been 
studying the blood as a whole. I shall now direct your attention to its 
more minute composition. Here, under the microscope, is a specimen show- 
ing the normal red corpuscles, as seen through a Leitz oil-immersion -^-^ 
and an ocular No. 3. 

All authors agree that there is a large number of these erythrocytes at 
birth, and also that an increase occurs in the first twenty-four hours. As 
regards the actual number in a cubic millimetre of blood there is much 
diversity of opinion. From the second day the erythrocytes begin nor- 
mally to diminish, and fall eventually, according to Lepine, Gerard, and 
Schlemmer, to 5,000,000. These authors found the loss of body-weight 
during the first twenty-four hours to be accompanied by an increase of the 
red corpuscles. Lupine attributed the variations to changes in the blood- 
plasma, and not to a new formation or to a degeneration of the corpuscles. 

Hayem always found a larger number at the moment of birth than in 
the mother's blood, and gives as an average 5,350,000. He states that 
tying the cord influenced the number, the average being perhaps half a 
million higher when the cord was tied late. This effect is temporary, how- 
ever, as is shown by Schiff 's experiments. When the infant's weight was 
lowest, Hayem found that the count reached its maximum. From this time 
a slow but constant diminution took place, and in the second week it was 
found to be about half a million less than at birth. He thought that the 
increase was due not alone to the loss of fluid, but also to the increased 
formation, because in maximal counts he found the corpuscles smaller, 
and considered them, therefore, younger. 

Stierlin examined older children, and found the erythrocytes to be very 
similar to those found in adults. There appeared to be more red corpuscles 
in each cubic millimetre of the blood of boys than in that of girls, about 
350,000 more. 

Schiff seems to have done the most thorough work on the estimation of 
the erythrocytes. He calculated the total blood quantity as well as he was 
able, and based his results on this. He found the highest count on the first 
day of life, and a diminution in the next few days, with hourly variations ; 



THE BLOOD IN INFANCY AND CHILDHOOD. 341 

but each succeeding day the count was lower. This shows the value of 
conducting experiments on the blood at the same hour of the day. The 
increase after birth is only seeming, according to Schiif, and is due to a loss 
of fluid and consequent concentration of the blood, because after the first 
feeding the counts are lower. He agrees with Lepine, except that he thinks 
the changes in the blood are not due to gain or loss in weight, but to the 
fluid taken into the system, and he showed that in a fasting infant, after 
several hours, there was an increase in the red corpuscles. Schiff places the 
average at birth at 5,800,000, and is unable to observe any influence of sex 
at this age. 

Leucocytes. — The white corpuscles are more numerous at birth than 
in adults or in young children. As I have already stated regarding the 
red corpuscles, the counts of the white corpuscles vary according to the 
examiner ; so that our knowledge of the exact figures which should repre- 
sent these counts is by no means settled. 

Schiff found the highest counts, in the first twenty-four hours following 
the first feeding, to be from 26,000 to 36,000 in a cubic millimetre. He 
never found the rapid diminution noted by Hayem at the end of a physio- 
logical loss of weight, nor did he find so low a count as 4000 to 6000 at 
this time. He called attention to the daily variation in consequence of 
digestion, which is of the utmost importance to bear in mind when ex- 
amining pathological blood. He estimated that from the t\N^elfth to the 
eighteenth day the average figures were from 12,000 to 13,000, and for older 
children 10,000. 

Hayem found that in the first few days of life there were three or four 
times more leucocytes than in adult blood, and his estimated average was 
18,000. His average of 5000 for adult blood is rather low. He found that 
this average of 18,000 persisted until the physiological loss of weight had 
ended, when it was rapidly reduced to from 14,000 to 12,000. At the time 
when the infant begins to gain in weight the count rises to from 19,000 to 
23,000, and there remains constant for a few days. The daily variations 
in the early days of life are more marked than in adults. 

Gundobin, in an examination of infants from ten days to a year old, 
found an average of 12,900, the variations being from 10,000 to 14,000. 
The adult variation he estimates to be from 7000 to 10,000. 

Bouchut and Dubrisay found the average of a number of counts in 
children from two to fifteen years of age to be 6700. 

Denis examined the blood of artificially fed and breast-fed infants. He 
found the diminution of the leucocytes occurring on the fourth day, and that 
it took place more rapidly in the breast-fed than in the artificially fed. He 
observed that the counts in infants were higher than in adults, and that 
an increase of the white corpuscles occurred in poorly nourished infants. 
He refers to the influence of food on the counts, and states that soon after 
feeding an increase in the leucocytes was observed. 

Anna Bayer, a pupil of Denis, estimates the leucocytes of new-born 



342 PEDIATEICS. 

infants and young children as between 16,000 and 23,000. In later child- 
hood, up to the sixth year, she placed them at from 9000 to 10,000. 

The cause of the leucocytosis of the new-born, according to Gundobin, 
is a predominance of the " over-ripe'^ elements (neutrophiles, Plate Y., 3), 
these cells forming from 60 to 80 per cent, of the total increase. He 
thinks this is due to a diminished activity of the retrograde metamorphosis. 
From the second day the process is more rapid, and from the seventh day 
to the tenth day the white corpuscles have reached their normal condition, 
which is found to be due to an absolute and relative increase of lympho- 
cytes, — that is, the blood becomes younger. 

Gundobin opposes Lupine's theory that the leucocytosis of the new-born 
infant is due to a concentration of the blood, and also Schiff^s theory that 
there is an increased flow of lymph from the tissues into the blood when 
the child is hungry. 

A fair average of the leucocytes in the blood of infants from six months 
to a year old is from 10,000 to 12,000. After the first two or three weeks, 
and up to six months, it is found to be from 12,000 to 14,000. Combining 
these observations as well as we can, I find the average figures regarding 
the number of the erythrocytes and leucocytes at different ages to be as I 
have represented in this table (Table 85). These figures assume a loss of 
weight for forty-eight hours and then a gradual gain. 

TABLE 85. (K. 0. Cabot.) 
Normal Average Number of Blood-Corpuscles at Different Ages in Cases where there was a 
Loss of Weight in the First Forty-Eight Hours. 
Age. Erythrocytes. Leucocytes. 

At birth 5,900,000 21,000 

(26,000 to 36,000 
after first feeding.) 

End of 1st day 7-8,800,000 24,000 

" 2d " generally increased. 30,000 

" 4th " 6,000,000 20,000 

" 7th " 5,000,000 15,000 

10th day 10-14,000 

12th to 18th day 12,000 

1st year , 10,000 

6th year and upwards 7,500 

After a meal 30,000 leucocytes is never an abnormal count in infants 
under two years. 

Nucleated Red Corpuscles (Plate Y., 6, facing page 330). — Neumann 
and K5lliker found large numbers of nucleated red corpuscles at birth (ery- 
throblasts of Ehrlich, the ^^ cellules rouges" of the French). Hayem, Luzet, 
Loos, Fischl, and other authors did not find these numerous erythroblasts, 
and say that they are found in large numbers in foetal life only. The few 
which are found are usually of the normoblast type. After six months they 
are rarely or never found normally. They are considered to be the result 
of delayed function. Pathologically, their presence may be of considerable 



THE BLOOD IN INFANCY AND CHILDHOOD. 343 

importance. Ehrlich divided them into three kinds, depending on their 
size and on the staining property of the nucleus : (1) the normoblast, which 
is the size of a normal red corpuscle, and has a small, deeply-stained 
nucleus ; (2) the gigantoblast or megaloblast, which is very much larger, 
perhaps three or four times, than the red corpuscle, and has a large, pale, 
or fragmented nucleus ; and (3) the microblast or poihiloblast, which is a 
very rare form, and corresponds to the microcyte in size. The normoblast 
is the tyj^e commonly found. 

LEUCOCYTES.— -Five varieties of white corpuscles are found nor- 
mally in human blood, and they have been classified in various ways. 
Ehrlich' s classification is as follows : 

1. Small Mononuclear, or Lymphocytes (Plate V., 1, facing page 
330). — These are small, round in shape, about the size of a red corpuscle, 
and contain a large round nucleus, which usually takes an intense stain 
with all basic stains. The protoplasm is a narrow band encircling the 
nucleus, and at times is so narrow^ as not to be visible. It sometimes stains 
faintly with eosin, and sometimes does not stain at all. These lymphocytes 
often vary much in size, and at times are so large as to be indistinguishable 
from the large mononuclear variety. 

2. Large Mononuclear (Plate V., 2, facing page 330). — These cells are 
considerably larger than the lymphocytes, often two or three times. They 
have a large oval or ovoid nucleus, which stains faintly, and a large amount 
of almost colorless protoplasm surrounding the nucleus and giving the cell 
very much the appearance of a vacuole. The protoplasm stains very faintly 
with eosin. 

3. Transitional Forms (Plate Y., 2a, facing page 330). — Among the 
large mononuclear cells there is found at times a transitional variety. Simi- 
lar in other respects to the large mononuclear corpuscles, they differ in that 
the nucleus is undergoing transition. This is shown by a more or less deep 
indentation, which gives to the nucleus a saddle-bag or horseshoe shape. 

4. Polynuclear, or more properly Polymorphnuclear, Neutrophiles 
(Plate Y., 3, facing page 330). — These corpuscles are somewhat smaller than 
the large mononuclear, more round in shape, and with a peculiar polymor- 
phous deeply-staining nucleus. At times the nuclei resemble the letters S, 
Y, Z, E. When stained the nucleus often appears segmented ; hence the 
name ^' polynuclear/^ The protoplasm is acidophilic ; that is, it has an 
affinity for acid stains, and is filled more or less completely with fine granules, 
which are not very refractive and are stained by neutral stains ; hence the 
name ^^ neutrophile." These corpuscles are more contractile than the other 
varieties, and are the ones most frequently found in pus, as they have the 
faculty of passing easil}^ through the walls of the vessels by means of 
their mobility. 

The last three named varieties are generally considered to be the same 
corpuscle undergoing metamorphosis, during which process the protoj)la>m 
becomes opaque and is changed from basophilic to acidophilic. The 



344 PEDIATRICS. 

opacity is due to the fine neutrophilic granules which have appeared in the 
protoplasm. This change is supposed to occur in the blood, and, according 
to Ehrlich, is due to some nutrient material present there. Possibly the 
corpuscles are better nourished in the blood than in the organs which are 
supposed to produce them. 

The transitional conditions are supposed by Uskow to be either a 
degenerative or a ripening process, of which the lymphocytes represent the 
'^ young" or "unripe cell/' the large mononuclear the '^ripe'^ cell, and 
the poly nuclear cells or neutrophiles the " old" or " over-ripe" cells. 

5. Myelocytes, or large Mononuclear Neutrophiles (Plate V., 8a, 
facing page 330). — These are large round or ovoid neutrophilic cells which 
probably originate in. the bone-marrow. They contain one, very seldom two, 
large round or slightly bent nuclei, which stain blue. The body of the cell, 
which forms a ring around the nucleus, is crowded with a quantity of fine 
neutrophilic granules. Myelocytes are rare in normal blood, but are much 
increased in some of the pathological states. (Klein.) 

6. Polynuclear Eosinophiles (Plate Y., 4, facing page 330). — These 
cells are generally about the size of neutrophiles, and have a nucleus, stain- 
ing deeply, which is similar to that of the neutrophile in shape and in its 
apparent segmentation. The protoplasm is acidophilic, and is more or less 
completely filled with coarse generally round or ovoid highly refractive gran- 
ules, which have an affinity for acid stains. The origin, significance, and 
composition of these cells have caused more discussion and research than 
those of any of the other varieties. Ehrlich states that the granules are not 
albuminoid, and concludes that their composition is of a complex nature. 
Weiss maintains that they are albuminoid, and bases his assertion on the 
results of micro-chemical experiments performed by himself and others. 
Ehrlich thought at one time that the only place of origin for these cells was 
the bone-marrow, and that their occurrence in the blood in large numbers 
signified chronic changes in the blood-making organs. Since then it has 
been satisfactorily demonstrated that they occur — pathologically, at any rate 
— in various secretions. Neusser found them in large numbers in the blood 
in certain skin affections. According to Canon, who verified this, the number 
was less dependent upon the disease itself than upon the amount of surface 
involved. They are frequent in the blood and bronchial secretion in asthma; 
also in the prostatic secretion under certain circumstances, and in the urine 
of septic nephritis. The number is normally very variable in the blood of 
infants and children, so that they have not the significance that they may 
have in the blood of adults. Weiss considers their increase as occurring 
entirely independently of the other leucocytes, and for this reason their 
comparative percentage has a doubtful value. 

7. Mononuclear Eosinophiles (Plate V., 86, facing page 330). — Very 
similar to the myelocytes are the so-called eosinophilic myelocytes. They 
differ from them in having in the cell protoplasm eosinophilic granules in 
place of neutrophilic granules. 



THE BLOOD IN INFANCY AND CHILDHOOD. 345 

8. Broken Cells. — In addition to the above-mentioned varieties, we 
find in some conditions of the blood polynuclear cells that have lost their 
regular outline and appear as though burst, with their granules scattered 
outside the cell-body. Their cause and significance are still matters of 
dispute. 

Granules. — By reason of their affinity for certain staining reagents, 
Ehrlich was enabled to differentiate seven varieties of granules occurring in 
the cells of the blood, five of which occur in the human blood. The 
staining fluids are divided into acid, basic, and neutral stains. The latter 
are obtained by combining a basic with an acid stain in certain proportions. 

This affinity for certain staining agents or groups of staining agents 
Ehrlich terms their elective power ; the degree of intensity with which they 
stain he terms their tinctorial poiver. He considers that but one kind of 
granule ever occurs in the same eel J, and then only in the protoplasm. He 
attributed the former of these phenomena to a specific secretory flmction of 
the protoplasm, and hence the term specific granulations which he applied 
to these granules. These granules differ in their reaction to staining fluids, 
in size, in shape, and in solubility. They are usually more or less round. 
Their size is about the same in each variety, but is markedly different in 
different varieties, the eosinophiles being the largest. 

The lymph-glands do not produce any cells containing granules, and 
Ehrlich believes that each variety must have its own peculiar protoplasm. 
He looks upon the granules as the product of cell activity, which is some- 
times a function of reserve material, and at other times is a process of elimi- 
nation. He found their composition to be complex. 

Ehrlich classified these five varieties of granules that are found in the 
white cells in human blood as follows : 

1. a Granules. — JEosinophilic. — Stained by all acid stains. They are 
neither fat nor albumin. (This has since been denied by Weiss.) These 
granules are coarse, round, and highly refractive. The leucocytes contain- 
ing them are present normally in the blood in small numbers. 

2. /5 Granules. — These are fine round granules stained by acid and basic 
stains (amphophilic), and occur in the medullary cavity of human bones, and 
in many of the leucocytes of rabbits and guinea-pigs. 

3. r Granules. — This variety is basophilic, and represents the German 
" mastzellen-kornung.^' They are moderately coarse, round, and not very 
refractive. They are said by Ehrlich not to occur normally in the blood. 
Other authors, however, have found them in small numbers. They are 
found in bone-marrow and connective tissue. They also occur pathologi- 
cally in the blood of leucaemia in varying numbers, and occupy more or less 
of the protoplasm of the large mononuclear cells. They are thought by 
most investigators to be pathognomonic of leucaemia when found in large 
numbers. 

4. d Granules. — These are basophilic, and are found in the mono- 
nuclear elements of human blood. The difference between this varictv and 



346 PEDIATRICS. 

the " mastzellen" granules, both of which are basophilic, has not yet been 
described by Ehrlich. 

5. £ Granules. — Neutrophiles. — These granules are stained by neutral 
stains, are very fine, are not refractive, and usually fill the protoplasm more 
or less completely of the polynuclear leucocytes with the exception of the 
eosinophiles. The nature of these granules is not known. This affinity for 
staining reagents is more than superficial, as a chemical reaction is supposed 
to occur. Weiss doubts whether the granules in the cells are the result of 
a specific cell function. The living cell is a very complex substance, with 
varied properties, morphological and chemical, and the granules may be 
formed in a number of ways and from chemically different substances to 
serve various purposes. 

Percentages of Various Leucocytes in Normal Blood. — Estimates 
have been made by many observers of the percentages of the different leu- 
cocytes in normal blood. It is sufficient to note that the blood of infants 
differs from that of adults in that the blood of the latter contains from 60 
to 75 per cent, of neutrophiles, the remaining 40 to 25 per cent, being 
made up of mononuclear cells, of which about 28 per cent, are lympho- 
cytes ; while in the infant the mononuclear cells, which include the lympho- 
cytes and the large mononuclear cells, form the majority of the cells, perhaps 
two-thirds or three-quarters, and in very young infants the percentage is even 
higher. The following table (Table S6) illustrates what I have just said : 

TABLE 86. 

Adults. Infants. 

Small mononuclear 24 to 30 per cent. 50 to 70 per cent. 

Large mononuclear . , 3 to 6 ** 6 to 14 " 

Neutrophiles 60 to 75 " 28 to 40 " 

Eosinophiles 1 to 2 " J to 10 " 

Gundobin finds very little change from the above figures until the 
beginning of the third year, when the blood resembles more that of adults, 
the neutrophiles and mononuclear elements being present in about equal 
proportions. In children of eight or ten years he found very little differ- 
ence from the blood of adults. 

His conclusions are that infants' blood is (1) richer in white corpuscles ; 
(2) richer in young form elements, the absolute and relative counts of the 
lymphocytes being three times as large as in the blood of adults, while the 
" over-ripe'^ elements, or neutrophiles, are half as many ; (3) in infants the 
white corpuscles remain relatively longer in the '^ unripe" and in adults in 
the ^' over-ripe" stage. 

Experiments have also been made to determine the constancy of the 
absolute number of white corpuscles and their relative percentages in healthy 
infants under different conditions. It is found that the longer the interval 
between the feedings the more marked is the increase in the white corpuscles 
during digestion. After two or three hours' fasting there is not much 



THE BLOOD IN INFANCY AND CHILDHOOD. 347 

change in the blood ; after five hours' interval there is always a leucocytosis 
averaging from two to four thousand. The cause is to be found in an abso- 
lute and relative increase of neutrophiles, the number of which corresponds 
to the increase. Morphologically, therefore, the blood is older. 

The time of day, variations in temperature, and physical exertion seem 
to have no effect upon the number of the white corpuscles. Most authors 
place the normal percentage of eosinophiles between 2 and 10 per cent. It 
is safe to say that they may be somewhat increased, even considerably, in 
infants' blood without having the same significance as in adults' blood. 

It may be of value to speak of certain sources of error in computing 
percentages which Weiss mentioned, — namely, that it is not enough to 
count the varieties of corpuscles of each kind, and thus estimate the per- 
centage of each, because you are then dealing with comparative and not 
absolute figures. It will readily be seen that if a leucocytosis is present, 
and one variety of corpuscle is increased, it must make the others appear 
relatively diminished, whereas they may be absolutely normal or even in- 
creased. The following table of Weiss shows this plainly : 

TABLE 87. 
Counts. Eosinophiles. 

1 300 

2 300 

3 .... , 600 

4 600 

This table shows how little reliance can be placed on a comparative count 
in a given case, for the percentages show a marked variation without being 
any index as to whether an actual change in the number of eosinophiles 
has occurred or not. In the first count they are normal; in the second 
they are absolutely normal and relatively diminished ; in the third they are 
absolutely increased and relatively diminished ; and in the fourth they are 
absolutely and relatively increased. This explains to some extent the 
contradictory percentages which have been reported. In order, therefore, 
to estimate an absolute increase of any variety a possibly concurrent leucocy- 
tosis must be taken into account. Another source of error mentioned by 
the same author lies in the staining fluid. Where acid and alkaline solu- 
tions are combined for staining purposes, it is possible, accidentally, for the 
alkaline solution to be so strong that not only do the coarse granules stain, 
but also the fine neutrophiles. Both have a red color, and a person depend- 
ing on the color alone might mistake the neutrophiles for eosinophiles. Tlie 
size and refraction of the granules should therefore be observed in every 
case. 



Total Leucocytes. 


Percentages. 


10,000 


3-h 


20,000 


1.5+ 


40,000 


1.5-h 


10,000 


6+ 



348 PEDIATEICS. 



IvKCXURE XV. 

THE PATHOLOGY OF THE BLOOD IN EARLY LIFE. 

Premature Infants — New-Born — Leucocytosis — Leuc^mia — Oligocythemia — 
Primary Anemias — Chlorosis — Anemia Progressiva Perniciosa — Anemia 
Infantum Pseudo-Leukemica von Jaksch — Secondary Anemias — Treat- 
ment OF Diseases of the Blood — Congenital Syphilis — Khachitis. 

From what I have in the previous lecture described to you concerning 
the elements of the normal blood, you will now be able to appreciate the 
conditions which occur in various diseases. So far as our present knowl- 
edge of the blood in early life goes, its general diseases may be disposed of 
quite briefly, only a few characteristic conditions from a diagnostic stand- 
point having as yet been discovered. Traces, however, of diseases which 
have caused changes in the blood are often observed for a long time, and 
may afford an estimate of the patient's condition. For instance, the haemo- 
globin is often comparatively low after the red corpuscles have reached their 
normal number, and thus affords an index to the rate of improvement. 

As I shall frequently refer to the expert work which has been done 
by Dr. Richard C. Cabot on this subject, I wish to acknowledge my appre- 
ciation of the careful manner in which he has verified my cases. 

I also wish to speak of the great assistance which I have received from 
Dr. John Dane, through his laborious work on and masterly grasp of this 
special branch of diagnostic medicine. 

PREMATURE INFANTS.— You may remember that in my lecture 
on Development I explained to you that premature infantile conditions 
are in one sense — namely, the developmental — closely allied to the patho- 
logical. It therefore seems proper to speak of the premature infant's blood 
before considering the abnormal conditions of the blood in early life. 

Here in Ward R is an infant (Case 104) premature at about the eighth 
month. 

BLOOD EXAMINATION 1. (Whitney and Wentworth.) 

Premature Infant, 8 months, thriving. 

Feb. 6. Feb. 9. Feb. 15. Feb. 27. 

Erythrocytes 5,118,750 5,023,750 5,072,500 4,500,000 

(a few nucleated.) 

Hffimoglohin 101 per cent. 98 per cent. 101 per cent. 91 per cent. 

Leucocytes 16,500 15,500 24,000 18,000 

Small mononuclear . 19 per cent. 47 per cent. 61 per cent. 39 per cent. 

Large " . 7 " 33 " 19 " 32 " 

Polynuclear .... 74 " 15 " 20 " 19 " 

Eosinophiles .... 5 " ? 10 " 



THE BLOOD IX IXFAXCY AXD CHILDHOOD. 349 

You will notice the high relative percentage of the lymphocytes, which 
you would expect in the early clays of life. The percentage of pol\'nuclear 
cells was extraordinary on February 6, especially when compared with the 
cotmt three days later. For an infant, this was a very marked neutro- 
philic leucocytosis, for which no cause could be ascertained. 

THE NE\^^-BORN.— Gundobin thinks that it is proper to speak of 
the new-born infant's blood as pathological. He considers that the mor- 
phological changes which occur in the blood during the first few days of 
life are not accounted for by the ordinary physiological conditions ; that the 
variations in the weight of the new-born and the quantitative and Cjualita- 
tive changes in the form-elements of the blood corresj^ond, so far as they 
are caused by the same processes ; that the probable cause of the morj)ho- 
logical and the chemical difPerences between the new-born infant's blood and 
that of the nursing infant is to be foimd in the de^dation from a normal 
tissue metamorphosis occiu'ring in the new-born ; finally, that the organism 
of the new-born infant shows very little power of resistance to pathological 
processes, and that the examination of the blood after Ehrlich's method 
shows better the length of the period of development usually designated by 
the term ^' new-born" than any other means. 

I have here another infant (Case 114), foiuleen months old, to show you. 

It is apparently perfectly healthy, but a physical examination shows that its growth has 
been retarded, and that it really only represents the development of an infant about seven 
months old, so far as its weight, teeth, and functions are concerned. The blood examina- 
tion presents characteristics which correspond to the stage of its development rather than 
to its age. Its blood therefore can be considered abnormal, but illustrative of an early 
stage of development. 

BLOOD EXAMI:N^ATI0:N'' 2. (WMtney and Wentworth.) 
Infant I4 months. Development corresponds to 7 months. 

Erythrocytes 4.928.750 

Haemoglobin 45 per cent. 

Leucocytes 23.000 

Small mononuclear 66 per cent. 

Large " 17 ■' 

Polynuclear 16 " 

Eosinophiles 1 *' 

With a few exceptions, such as malaria, leucaemia, chlorosis, anremia 
progressiva perniciosa, and anaemia infantum pseudo-leu kae mica von Jaksch, 
it is hardly wise at present to attempt to classify changes in the ele- 
ments of the blood, according to their origin, into primary and secondary 
diseases. I shall therefore merely explain to you exactly what was found in 
my examinations of the blood in various diseases, ^^ith the hope that this 
work may aid you in understanding the far more extensive investigations 
which are being made in Europe. 

There are certain changes in the blood which occur under varying condi- 
tions, both physiological and pathological. They are quite wmmouly met, 



350 PEDIATRICS. 

and are found in many different diseases, whether the diseases are primary 
in the blood itself or are merely represented secondarily by the changes in 
the blood. These general changes may be divided into two broad classes, 
(1) leucocytosis and (2) oligocythsemia, and I think that you will better 
understand what I shall say concerning the blood in each disease if I first 
describe these general classes, with, so far as is possible, the especial diseases 
which belong to them. 

LEUCOCYTOSIS. — The best definition of leucocytosis that I can give 
you is one that has been formulated by Dr. Richard C. Cabot. He says 
that '"' leucocytosis is the presence in the blood of an increased number of 
white cells of the same varieties morphologically as those in normal blood, 
a plurality, and generally an overwhelming plurality, being polynuclear." 
Physiologically, we find a leucocytosis after the ingestion of any proteid food. 
It is at its height about two hours after a meal, when the total number of 
leucocytes may be as great as from 13,000 to 30,000, according to the age 
of the child. Pathologically, a leucocytosis follows a considerable number 
of diseases, and seems in a general way to depend upon the amount of local 
reaction to which the disease gives rise. We find a pronounced leucocytosis 
in most fevers and in most septic processes. Von Limbeck, in his article on 
inflammatory leucocytosis, says that a leucocytosis not only accompanies 
an exudation, but "corresponds in degree to the number of cells in the 
exudation ; that is, whether it is serous or purulent.'^ Of the pyogenic 
bacteria he says that the staphylococcus seemed most productive of leuco- 
cytosis, especially the pyogenes aureus. It is not known why this should 
be so. In these cases the increase is almost wholly composed of the poly- 
nuclear neutrophiles, which may make up from 90 to 98 per cent, of the 
entire leucocyte count. 

Although I shall have occasion, in showing you cases in the wards, to 
speak in detail of many of the diseases that give rise to a leucocytosis, 
I will now briefly enumerate them. Pneumonia shows generally a leuco- 
cytosis, and especially if the case is to have a favorable termination. In 
pneumonia the large increase in the number of leucocytes seems to follow 
closely the course of the pathological process, and the " blood crisis" is 
found to anticipate the " temperature crisis" by some hours. Pericarditis 
and endocarditis, advanced phthisis, pleuritis, erysipelas, acute rheumatism, 
purulent meningitis, pharyngitis, diphtheria, septicsemia, osteo-myelitis, 
scarlet fever, variola, some profound anaemias, whether primary or second- 
ary, leucsemia, hemorrhage, malignant new growths, abscess of any kind, 
including appendicitis, and many skin diseases, are among the others that 
show leucocytosis. The diseases in which the leucocytes are approximately 
normal are malaria, tubercular meningitis, tubercular and serous peritonitis, 
influenza, measles, typhoid fever, and pulmonary phthisis unless there is 
a secondary infection by other bacteria. Comparing these two lists, you 
will see that there are some cases in which the leucocyte count may be of 
great importance to the physician in making a differential diagnosis. By 



THE BLOOD IN INFANCY AND CHILDHOOD. 351 

its aid we may in some cases differentiate scarlet fever from measles, a puru- 
lent from a tubercular meningitis, and a beginning pneumonia from a tuber- 
cular meningitis or typhoid fever. Lastly, we may by the leucocyte count 
alone be able to decide between sepsis and malaria in a patient whose only 
symptoms are malaise and returning chills. 

Leuc^mia. — The disease called leucaemia sometimes occurs in infancy 
and childhood. Klebs, von Jaksch, and Sanger describe congenital cases. 
On the whole, it is a rare disease in infancy, and when it occurs it is 
probably always a mixed form. A pure myelogenous form of leucsemia 
is very rare. The etiology of the disease is obscure. Cases have been 
reported which followed congenital syphilis and rhachitis. It is thought 
by some to be an infectious disease, but the evidence is insufficient. Von 
Limbeck thinks that it is a disease of the lymphatic system. Others say 
that any anaemia or Hodgkin's disease may progress to leucaemia under 
certain circumstances, as may also anaemia infantum pseudo-leukaemica. A 
number of cases are apparently primary. This is one of the few diseases 
which can be diagnosticated definitely from the blood-examination alone. 

Speaking of the haematology of leucaemia, we find that it occurs in two 
distinct varieties, according as the lymph-glands or the spleen and bone- 
marrow have been most affected. I will begin with a short description of 
the latter, the spleno-myelogenous. The first and perhaps the most striking 
thing that you will notice in examining the blood is the great increase in 
the leucocytes. Von Jaksch reports a case in an eighteen-months infant 
where the figures were 1 to 18, and another in which the astonishing ratio 
of 1 to 2.5 was found. But a leucocytosis alone, even a profound one, does 
not make a leucaemia ; it is the especial kind of leucocyte that you must 
depend upon, the so-called myelocytes, or " markzellen" of Ehrlich (Plate 
v., 8a, facing page 330). These cells, which are said never to be found in 
normal blood, are present in this disease in varying proportions up to 20 per 
cent, of the entire leucocyte count, or even higher. Associated with these 
there may be the eosinophilic markzellen (Plate V., 86, facing page 330), 
which Rieder and others have held to be equally diagnostic ; also the dwarf 
eosinophiles (Plate Y., 46, facing page 330), which differ only in size from the 
ordinary polynuclear eosinophilic cells. These three varieties of elements 
are found in great numbers in the marrow of the long bones, and thence are 
supposed to get into the blood. Of the forms of leucocytes with which 
you are familiar in normal blood you may find the polynuclear eosinophiles 
increased. Their variation was thought at one time to be of diagnostic 
importance, but it is now considered to be of no value. The polynuclear 
neutrophiles are normal, or frequently are relatively diminished and vary 
in size more than usual. The lymphocytes in pure spleno-myelogenous 
leucaemia are always diminished. Karyokinesis is marked in the leucocytes. 
The erythrocytes you will find reduced, but never so much so as in the 
primary or even the secondary anaemias. The percentage of haemoglobin 
decreases proportionately with the number of red globules or slightly in 



352 PEDIATRICS. 

advance of it. Lastly, nucleated red cells appear, mostly normoblasts, 
though megaloblasts are not very rare in children. 

Turning now to the second or lymphatic variety, the blood-picture is 
very different, though quite as distinctive. In this the leucocytes are never 
so greatly increased, and seldom exceed the proportion of 1 to 15. The diag- 
nosis rests upon the wonderful relative increase of the lymphocytes. These, 
as you know, should make 25 to 60 per cent, of the entire leucocyte count, 
according to the age of the child ; but in this form of leucaemia 90 per cent, 
and over has been reported, even in adults. Relative to these, all the other 
leucocytes are diminished. The special cells, which I have told you are 
found in varying proportions in the spleno-myelogenous form, are rare ; 
perhaps their occasional presence may be explained by a slight involvement 
of the bone-marrow, even in the purest lymphatic form. 



Case 115. (Damon and Cheever. 




Warren Museum, Harvard University. Lymphatic leucaemia. Boy, 8 years old. 

This case (Case 115), the history and picture of which I have brought from the Warren 
Museum to show you, is that of a boy eight years old, reported by Dr. H. T. Damon. He 
had shown symptoms of enlarged cervical glands for a year, but his general health had 
been fairly good. He never had any pain in the glands, and was well enough to go to 
school. An examination of the blood showed that the relation of the leucocytes to the 
erythrocytes varied from 1 to 50 to 1 to 10. 

Two months previous to the time when this picture was taken, the tumor had increased 
rapidly, and you see it is of considerable size, involving the entire left side of the neck. 
The boy complained at this time of headache, which probably was caused by pressure on 
the recurrent vessels of the neck. The mass of impacted glands had begun evidently to 
press upon the trachea, and on exertion the respiration was slightly interfered with. On 
palpation the tumor was found to consist of many lobules, which were to some extent mova- 
ble, and appeared to be made up of an enlarged chain of lymphatic glands. It extended 



THE BLOOD IX IXFAXCY AXD CHILDHOOD. 353 

from near the middle line of the neck in front, back upon the edge of the trapezius on the 
left side, and above from the lobe of the ear and angle and body of the lower jaw down to 
and beneath the clavicle. The left shoulder was depressed by it. A number of enlarged 
cutaneous veins ran over it in various directions. As the tumor showed no signs of soften- 
ing, but was steadily enlarging, it was deemed best to attempt its removal. The operation 
was performed by Professor D. W. Cheever. An incision was made from just below the 
ear to near the cricoid cartilage, through the skin and platysma, and disclosed a lobulated, 
hard, glandular mass, lying mainly beneath, and partly behind, the sterno-mastoid muscle.. 
Contrary to expectation, it was found very adherent in all directions, and the lobules were 
bound together by strong fibrous tissue. Considerable time and care were requisite to 
divide the adhesions, which were too strong to yield to anything but the edge of the knife. 
It was found necessary to divide the sterno-mastoid, and to dissect aside the external jugu- 
lar, which ran, somewhat displaced, over and through the tumor. The lower edge of the 
tumor extended beneath the clavicle, into and below- the subclavian triangle. The base lay 
over the sheath of the carotid, which was necessarily exposed for about two inches. Con- 
tinuous dissection was required, even to the last adhesion, for they could nowhere be made 
to yield. 

The boy recovered in a few weeks, a large part of the wound healing by first intention. 

The tumor was found to consist of a lobulated mass of hypertrophied lymphatic glands, 
firmly bound 'together by investing fibrous tissue. 

Two years after the operation the child was alive and fairly well, although the glands 
on both sides of the neck were again found to be considerably enlarged, as wero also those 
in the axilla. The further history of the case is unknown, and the report is in many ways 
unsatisfactory, but the facts as stated are all that I could ascertain about it. There is no 
doubt in my mind that it was a case of leucaemia. 

The second general class, which I have referred to as liable to occur in 
many diseases, is oligocvthsemia. 

OLIGOCYTHEMIA. — The anaemias are of common occurrence in 
infancy and childhood. Our ordinary methods of examination are evi- 
dently insufficient to discover the causes of the anaemia. It seems as if m 
the future we must direct our attention to other methods of investigation, 
and especially to the examination of the blood-serum. It may be of 
interest to refer briefly to Maragliano's recent theory regarding the blood- 
serum and its action on the corpuscles. IMaragliano's researches upon the 
blood-plasma have tended to show the various relations existing between 
the organs and the blood. Pronounced local pathological changes in- 
fluence the composition of the blood-serum, so that in consequence of 
this the corpuscles later are destroyed. The length of time required to 
produce this result depends upon their resistance. These observations 
throw light on a number of clinical results, and on the dependence of 
the anaemias upon severe pathological disturbances. Maragliano found that 
the erythrocytes, when pathological conditions were present in the serum, 
were rapidly destroyed, whereas in healthy serum they remained almost 
intact. He examined the blood serum in various diseases, as, for instance, the 
essential anaemias of all grades, carcinoma, saturnismus, spleno-myelogeuous 
and lymphatic leucaemia, purpura, cirrhosis of the liver, nephritis, pneu- 
monia, typhoid fever, erysipelas, and tuberculosis. In all these diseases the 
serum has a destructive effect on the corpuscles as compared with normal 
serum, but with quantitative diftereuces depending on two factors: (1) the 

23 



354 PEDIATRICS. 

vulnerability of the red corpuscles, and (2) the destructive power of the 
serum. If both of these factors work together, the effect produced is ex- 
treme. He is very cautious about explaining the cause, but denies any 
definite relation between the amount of albumin and the destructive power 
of the serum, and rather inclines to the belief that the quantity of salts in 
the serum has some influence. While the erythrocytes are being destroyed, 
however, the blood-making organs are undergoing an increased functional 
activity, and producing erythrocytes to supply the loss. Maragliano con- 
cludes that different conditions of the serum produce in the red corpuscles 
all the appearances of necrobiosis, and can even destroy them. This gives 
an anatomical, physiological, and pathological basis for our belief in inde- 
pendent diseases of the blood. This theory concerning the blood-serum is 
at least plausible, and until it has been proved incorrect it may be accepted. 
Perhaps this necrobiotic power of the serum, which depends on some pre- 
vious disease, varies in different diseases and in different individuals. Even 
if it is present in sufficient amount to cause anaemia in a given case, it may 
not do so because of the resistance of the blood-corpuscles to its influence. 
The variation in these two factors — namely, the resistance of the red corpus- 
cles and the destructive power of the serum — will account for the variation 
in the degree of anaemia produced in different individuals having the same 
disease. 

We know that in distilled water the coloring matter of the red corpus- 
cles is extracted from the stroma, but when a certain percentage of sodium 
chloride is added to the water the integrity of the red corpuscles is pre- 
served. That the erythrocytes are not normally destroyed by the serum in 
which they float seems to depend upon the presence of a sufficient quantity 
of salts in the serum. A serum in which there is just enough saline matter 
to preserve the red corpuscles has been called by Hamburger ^' isotonic.'' 
But as an isotonic serum would easily lose its protective properties, owing to 
its dilution after each meal, we generally find a higher salt percentage than 
is necessary to preserve the red corpuscles, — a condition designated by the 
term ^^ hyperisotonic.'' 

From experiments upon animals it has been proved that the serum pos- 
sesses powerful germicidal properties, which are easily destroyed by raising 
the blood to a temperature of 55° C. (131° F.) for a short time or by ex- 
posing it to light. Still more singular is the fact that not only does the 
mixing of the serum of one animal with the blood of another of a different 
species destroy its germicidal power, but also that the added serum acts as 
a solvent for the red corpuscles and renders the white corpuscles inactive. 
There is considerable reason to believe that immunity from a given disease 
depends upon the character of the serum ; and Klemperer is now carrying 
on some interesting experiments with a view to producing immunity by 
serum inoculation. 

In regard to what are usually looked upon as primary anaemias, we can 
speak of such diseases as chlorosis, pernicious anaemia, and anaemia infantum 



THE BLOOD IN IXFANCY AND CHILDHOOD. 355 

pseudo-leuksemica (von Jaksch). By far the greater number of anaemias in 
early life are, however, of secondary origin. Hemorrhage, the acute infec- 
tious diseases, syphilis, rhachitis, new growths, intestinal affections, and dis- 
eases of the respiratory system, skin, and bones, are the ordinary causes of 
secondary anaemia. The degree of the anaemia depends upon the individual, 
upon the severity and length of the disease, and upon other causes which 
are as yet unknown. The secondary anaemias may be either of a mild 
or of a severe form, and may be accompanied or not by a greater or less 
degree of leucocytosis. The mild forms are usually spoken of as anaemia 
chronica levis, while the severe forms may be called ancemia chronica gravis. 
The blood in these cases shows a varying degree of oligocythaemia and oli- 
gochromaemia, with or without leucocytosis, and, if severe enough, poikilocy- 
tosis, microcytosis, and at times nucleated red corpuscles. The latter are the 
more frequent the younger the child, and generally occur dm^ing the first 
year. They are never very numerous in these cases, and are, as a rule, of 
the normoblast type. 

Primary Anemias. — Poor as the classification of the anaemias into 
primary and secondary may be, it will, I think, keep the subject more 
clearly before your minds if I follow this very imperfect division, which for 
purposes of simplicity it has seemed almost necessary to make. I shall 
therefore speak at once of the anaemias which are supposed to be primary 
and which I have just enumerated, wishing it, however, to be imderstood 
that I use the word primary only provisionally until further light is thrown 
upon this class of diseases. 

Chlorosis. — Although it is still a matter of dispute whether chlorosis 
should be classed as one of the anaemias, it will simplify what I have to say 
on this subject if I speak of it as such. 

Weiss doubts if chlorosis occurs in infants and young children, but 
the observations of Henoch and others tend to show that it does. The 
distinguishing characteristic of the disease is the very low percentage of 
haemoglobin relatively to the nearly normal number of erythrocytes, which 
is in marked contrast to that found in other diseases, especially progressive 
pernicious anaemia. There is very little or no leucocytosis. Considerable 
variation in the size of the erythrocytes occiu-s, poikilocytes, microcytes, and 
macrocytes being often found. 

In this connection I will refer you to some interesting work on the 
intestinal origin of chlorosis which has been done by Dr. Forchheimer, of 
Cincinnati, and to his original views and new definition of this disease. 



This infant (Case 116), eighteen months old, has never had the symptoms of any 
special disease beyond a pallor of the nails, skin, lips, and mucous membrane of the gums, 
with loss of appetite and strength. This has lasted for about six months, and does not 
appear to depend on climate or habitation, as the infiint has been during this period in a 
number of houses, both in the city and at the sea-shore. An examination oi the blood 
showed that it was a case of chlorosis, the erythrocytes being somewhat reduced and there 
being a decided olio-ochromaemia. 



356 PEDIATRICS. 

BLOOD EXAMINATION 3. (Wentworth.) 

Erythrocytes 4,427,500. 

Hsemoglobin 35 per cent. 

(The infant gradually improved under a course of treatment which was largely 
dietetic.) 

The next case (Case 117) which I have to report is that of a female infant, eleven and 
one-half months old. The pallor of the lips, gums, skin, and nails in this case was 
extreme, and was accompanied by loss of appetite, but no especial emaciation. The blood 
examination gave the following result : 

BLOOD EXAMINATION 4. (Whitney and Wentworth. ) 

Erythrocytes 4,470,000 

Hsemoglobin 30 per cent. 

Leucocytes 25,000 

Small mononuclear 45 per cent. 

Large " 21 " 

Polynuclear 30 " 

Eosinophiles 3 " 

The cause of the chlorosis was apparently arsenical poisoning from wall- 
papers. The chlorosis was always extreme during the nine months of the 
year when the infant was in its winter home, and was unaifected by treat- 
ment, either dietetic or medicinal. During the three summer months that 
it was away from home it decidedly improved, but it immediately grew 
worse on returning. The papers throughout the house in its winter home 
were found to be dangerously arsenical, and on their removal the infant 
rapidly improved, and in a few weeks regained its healthy color, strength, 
and appetite. If the chlorosis in this case was caused by arsenic, it must 
of course be classed with the secondary anaemias. 

Both these cases illustrate the fact that extreme pallor does not neces- 
sarily indicate a great reduction in the number of the erythrocytes. 

The symptoms of this disease as met in infants are progressive loss of 
appetite and of strength, and extreme pallor of the skin and of the mucous 
membrane, not accompanied, as a rule, by marked emaciation. 

Ansemia Progressiva Perniciosa. — I shall next speak of a very 
severe form of primary ansemia, the prognosis of which is so serious that 
it is called ancemia perniciosa. 

Biermer in 1868 described a disease under the above title, and said that 
it developed apparently without any cause and by a gradually increasing 
and constantly progressing ansemia caused death. The pathological and ana- 
tomical changes consisted in a great diminution in the amount of blood in all 
the organs, with marked fatty degeneration of the heart, blood-vessels, liver, 
and kidneys. Capillary hemorrhages were frequently found. Since then a 
mass of literature has been accumulating on the subject. Various authors 
have observed cases in infancy and in childhood. Most of the cases, how- 
ever, were over a year old, and it is certainly not a common disease of early 
childhood. The description of the disease does not differ materially from 



THE BLOOD IN INFANCY AND CHILDHOOD. 357 

that of adults. There is an apparently spontaneous beginning in most cases. 
Klebs and Frankenhauser thought that they found certain micrococci in the 
blood, but this has not been proved. Cases have been recorded which have 
developed as a result of congenital syphilis, and there are other cases in which 
the presence of such intestinal parasites as the anchylostoma duodenalis and 
the bothriocephalus latus have appeared to be followed by it. Cases have 
also apparently followed repeated hemorrhages. The majority, however, 
occurred without any discoverable cause. 

The blood in pernicious anaemia is thin and light-colored, and all the 
formed elements are markedly decreased. The enormous diminution of 
erythrocytes, which is more marked than in any other disease, even in the 
highest grade of simple secondary anaemia, the relatively high haemoglobin 
percentage, due to the large amount of haemoglobin in each corpuscle, and 
the presence of megaloblasts in large numbers, are considered to be diag- 
nostic of this disease. Poikilocytosis is usually pronounced. Microcytes 
and macrocytes are common. There is generally a diminution in the 
number of leucocytes, the prevailing type being mononuclear, but at times 
we find a distinct leucocytosis. It has been pointed out by von Jaksch that 
the degree of leucocytosis is never so great as in anaemia infantum pseudo- 
leukaemica. Eosinophilic cells are, as a rule, present in unusual numbers. 
Myelocytes in small numbers are not infrequently found. Clinically the 
disease does not differ from that of the adult. It is the severest type of 
all the anaemias, and all the cases have proved fatal, except those in which 
intestinal parasites were found to be the cause and were removed before 
the disease had become folly established. 

This infant (Case 118), six months old, is apparently a case of pernicious anaemia, 
although the blood examination does not entirely establish the diagnosis. It entered the 
hospital when it was five and one-half months old, with the history of having been fed on 
a variety of patent foods from the time of its birth. On physical examination nothing 
abnormal was found in the abdomen or thorax, and it was not especially atrophic. Its 
weight was 2841 grammes (6^ pounds). It now weighs 2915 grammes (6f pounds). Since 
entering the hospital it has failed to respond to treatment of any kind, whether dietetic or 
medicinal, and has become more and more anemic. You will notice the extreme pallor 
of the mucous membrane of the gums and of the entire skin. The following is the report 
of the examination of the blood : 



BLOOD EXAMINATION 5. (Whitney and Wentworth.) 

Erythrocytes 2,937,500 

Haemoglobin 35 per cent. 

Leucocytes 5,500 

Small mononuclear 55 per cent. 

Large " 10 " 

Polynuclear 35 '• 

Eosinophiles 5 " 

(The infant continued to fail progressively, and died about two months later. The 
temperature and pulse were practically normal through the whole course of the disease. 



358 PEDIATRICS. 

and nothing abnormal was at any time detected in the thorax or abdomen. There was no 
autopsy. A few days before death there appeared extensive hemorrhages under the skin 
of the abdomen.) 

This infant (Case 119), seventeen months old, presents the typical appearance of a per- 
nicious anaemia. On entering the hospital it weighed 5925 grammes (13.03 pounds), and 
has been progressively losing, until this morning its weight was only 5798 grammes (12.75 
pounds). It is emaciated and has had but little appetite, but it has evinced a desire to eat 
any dirt that it can lay its hands on, A physical examination reveals nothing abnormal, 
such as thoracic disease, enlarged spleen, or enlarged lymph-glands. The skin has the trans- 
parent rather waxy appearance (well represented in Plate V., facing page 330, Anaemia 
Infantum Pseudo-Leuksemica von Jaksch) which occurs in anaemias of the highest grade. 

Case 119. 




Ansemia perniciosa. Female, 17 months old. 

She is rather apathetic, in fact, almost dull, and can be handled and examined with- 
out any apparent discomfort. The result of the blood examination is very significant : 

BLOOD EXAMINATION 6. (Wentworth.) 

Erythrocytes 1,022,500 

Haemoglobin 17 per cent. 

Leucocytes 16,000 

The next case (Case 120), an infant nine months old, was seen by me in consultation 
with Dr. C. P. Putnam, who has kindly provided me with its previous history. The in- 
fant was healthy at birth, and up to the time of its present sickness had never had any 
disease. For several months it had progressively grown pale, and its appetite had decidedly 
lessened. It had not, however, lost materially in weight, but had grown weak physically, 
and its mental hebetude had been so noticeable that a suspicion had arisen that it was lack- 
ing in cerebral development. On inspection the infant seemed moderately fat, but the 
muscles were soft, and the skin was of an extremely pale and waxen tinge. It was evi- 
dently very weak. On physical examination nothing abnormal was detected about the 
head, thorax, or abdomen. All the organs seemed to be of natural size. An examination 
of the blood, made by Dr. Dane, resulted as follows : 

BLOOD EXAMINATION 7. (Dane.) 

Erythrocytes 1,571,000 

Haemoglobin 22 per cent. 

Leucocytes 19,100 

Small mononuclear 42 per cent. 

Large " - 18 " 

Polynuclear 40 " 

Eosinophiles " 



THE BLOOD IN INFANCY AND CHILDHOOD. 359 

You will notice the great reduction in the number of red corpuscles, the relatively 
large percentage of haemoglobin, and the slight increase of white cells. The differential 
count gives us no special information in regard to the cause or character of the disease. 
(The child died a few days later without showing any other symptoms.) 

The next case is the fourth in which the clinical history and the great 
oligocythsemia seemed to point towards ansemia perniciosa as the most prob- 
able disease, but no elaborate blood examination was made. 

A female infant (Case 121) entered my wards at the Children's Hospital on the 16th 
day of April. She was then nine months old. Nothing abnormal was detected in the 
lungs or heart, and there was no appreciable enlargement of the liver, spleen, or lymph- 
glands. The pulse varied from 120 to 140, and the temperature from 36.7° C. (98.06° F.) 
to 37.8° C. (100.04° F.). The respiration was from 44 to 68. There were hemorrhagic 
spots on the ankles and head for a few days, but these soon passed away, and nothing 
abnormal was detected except extreme pallor of the skin, progressive loss of appetite, 
emaciation, and quick respiration. The erj'throcytes were reduced to 785,000, and there 
was marked poikilocytosis. There was a slight amount of albumin in the urine. The 
infant grew rapidly worse on April 22, and died in the evening. There was no autopsy. 

Anaemia Infantum Pseudo-Leuksemica (von Jaksch). — I shall now 
speak of a form of chronic primary anaemia where, in order to make a 
differential diagnosis, we must consider the etiology and physical signs as 
well as the blood examination. 

Von Jaksch, in 1889 and 1890, was the first to describe this disease and 
give it this title. Since then it has been the subject of much investigation 
and contention. Von Jaksch based his diagnosis on the following points : 
that it was a disease of infancy, characterized by marked oligocythsemia, 
oligochromsemia, considerable permanent leucocytosis, marked splenic en- 
largement, at times enlarged lymph-glands, only moderate or slight enlarge- 
ment of the liver, and clinically to be differentiated from leucaemia by the 
disproportion existing between the size of the liver and the spleen. The 
more favorable prognosis is also an aid in the diagnosis. About the same 
time Hay em described a similar disease in a child, and noted the presence 
of numerous nucleated red corpuscles. Von Jaksch had noticed them, but 
had mistaken them for leucocytes having erythrocytes inside of them. 
Hayem noted especially that many of the nucleated red corpuscles were 
undergoing mitosis. This had never been observed before in the circulating 
blood. 

Luzet verified Hayem's observations. He described this as a disease of 
early infancy, and emphasized the chronic course, the intense anannia, and 
the large size of the spleen and the liver without enlargement of the lymph- 
glands. He only found a slight leucocytosis, in which the eosiuophiles 
were quite numerous. He considers the large number of nucleated red cor- 
puscles, many of them showing mitosis, as especially important for diagno- 
sis. This condition he has not found so marked in any other disease of the 
blood. He considers this one of the rare affections of infimcy, as accoixling 
to his statistics it was met only once in fifteen hundred cases of aua^nia, and 



360 PEDIATKICS. 

he thinks that it does not occur after two years of age. The eifects of sex, 
temperament, habitation, heredity, and climate are not known. 

He thinks that rhachitis and syphilis, which at times produce anaemia, 
with enlarged spleen, do not cause anaemia infantum pseudo-leukaemica. 
Loos, Weiss, Somma, and others have written a great deal about this dis- 
ease. Some of them consider it an infectious disease. Most of them deny 
that it has any connection with malaria, syphilis, and the digestive disturb- 
ances, and only occasionally mention its connection with rhachitis. 

As a result of my investigations of a considerable number of cases of 
anaemia of every grade in young infants, it seems to me that we have 
arrived at a degree of knowledge which justifies us in making a diag- 
nosis, in certain cases, of anaemia infantum pseudo-leukaemica von Jaksch, 
and I shall presently show you some cases illustrative of this disease. 
We are dealing with a disease of infancy characterized by a chronic course, 
rather rare occurrence, and etiological obscurity. The clinical symptoms 
are those of a grave anaemia, with a ^^ waxen" appearance of the skin. 
The child may be somewhat atrophied, but is often fairly nourished. There 
is always considerable splenic enlargement, with only moderate or slight 
enlargement of the liver. The lymph-glands are generally somewhat 
enlarged, but never form packets. The blood is characterized by marked 
oligocythaemia and oligochromaemia, together with a leucocytosis which is 
often considerable. Nucleated red corpuscles of all types are very numerous, 
and many of them are found to be undergoing mitosis in their nuclei. Poi- 
kilocytosis is marked. The polychromatophilic condition of the red cor- 
puscles, mentioned by Alt and Weiss, may occur. The eosinophilic cells 
vary in number, and at times are much increased. They also vary con- 
siderably in size. Occasionally small numbers of the large mononuclear 
neutrophiles and the eosinophilic '^ markzellen" of Miiller and Rieder are 
found. (Klein.) 

The course of the disease varies. Von Jaksch lays stress on the more 
favorable prognosis as compared with leucaemia. All of my cases have 
been fatal without any apparent complication, and even if the disease 
remains stationary for a time the risk from intercurrent disease is great. 
Four cases which apparently can be classed as representing this disease 
have occurred in my practice. The first case (Case 122) you will remember 
seeing in my wards at the Children's Hospital, and may be described as 
follows : 

A boy, three years of age ; had never had any disease, with the exception of a ques- 
tionable malaria, from which he had entirely recovered two years previously. The father 
said that since his second year he had looked pale, and that a physician was consulted about 
him eight months before he entered the hospital. He entered my wards on October 4. The 
child, as you will remember, was of a waxen color, well shown in Plate V. (facing page 
330), and the mucous membrane of the lips and nails was nearly white, with a livid tinge. 
The skin was almost translucent. There was not much emaciation. The spleen was con- 
siderably enlarged, and could easily be felt about two inches below the border of the ribs. 
The liver was slightly enlarged and could be felt upon palpation. The glands were enlarged 



THE BLOOD IN INFANCY AND CHILDHOOD. 



361 



to the size of peas in the neck, axillae, and groins. On percussion the heart showed no 
enlargement. A loud systolic murmur was heard over all the cardiac orifices. The action 
of the heart was very rapid, but regular. Its impulse was in the fifth interspace inside of 
the mammary line. Auscultation and percussion of the lungs showed that they were nor- 
mal, with the exception of some sibilant rales. The respirations were 30 to 44 in a minute. 



Case 122. 




Anaemia infantum pseudo-leuksemica von Jaksch. Male, 3 years old. 

liver, and spleen outlined in black. 



Lower border of ribs, enlarged 



The temperature at entrance was 38.3° C. (101° F.), and afterwards varied from 39.5° C. 
(103.8° F.) to about 38.3° C. (101° F.). The pulse varied from 125 to 150. Diarrhoea was 
present when the child entered the hospital, and at first there were four to six very offensive 
movements daily. For three or four days preceding death the movements were more fre- 
quent, but were not so offensive, and contained mucus. Vomiting occurred at times. The 
infant was treated with modified milk, bismuth, and stimulants. An examination of the 
blood, October 13, resulted as follows ; 

BLOOD EXAMINATION 8. 

Erythrocytes 1,295,000 

Haemoglobin 15 per cent. 

Leucocytes 64,500 



There were numerous poikilocytes, microcytes, and megalocytes. A number of the 
corpuscles were pale, and many of them contained very little haemoglobin. 

The polymorphous character of the blood was very marked. There were numerous 
nucleated red corpuscles (Plate V., 6, facing page 330), chiefly of the normoblast type, and 
in many of them the nuclei were undergoing subdivision. The eosinophiles were absolutely 
and relatively increased. None of the " markzellen," characteristic of leucivmia, were 
present, and the leucocytes were largely of the polynuclear variety. The child died October 
20, and a partial autopsy was obtained. 

A microscopic examination showed no evidence of leuciemia in the liver, spleen, 
kidneys, or lymph-glands. There were no evidences of syphilis or rhuchitis, nor of any 
inflammation which could have caused the leucocytosis. 



362 



PEDIATRICS. 



My second case (Case 123) of this disease I happen to have here in the 
wards to-day to show you. It is a male infant, eleven months old. 

The previous history of the infant has not been ascertained, as the parents have disap- 
peared. You see that he is poorly developed and somewhat emaciated. The skin has a 
waxen color, and the mucous membrane of the lips and gums is almost colorless. The 
dejections are frequent; they contain partially digested blood, and have so offensive an 
odor that disinfectants are constantly required in the room. The cervical lymph-glands 
and those in the groins are slightly enlarged. I find nothing abnormal on examining the 

Case 123. 



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Ansemia infantum pseiKlo-leukaimiea vok Jakseh. Male, 11 months old. Left lower border of ribs, 
ensiform cartilage, and enlarged spleen marked in black. 



Case 123. 




Angemia infantum pseudo-leukpemica von Jakseh. Male, 11 months old, crying. Right lower border of 
ribs, ensiform cartilage, and enlarged liver marked in black. 



heart and lungs. Palpation of the abdomen reveals a large tumor of firm consistency, 
beginning under the lower border of the ribs in the left axillary line, and extending 
towards and considerably below the umbilicus. This tumor is evidently the spleen, and 
you see I have outlined its edge in black. On the right side of the abdomen the edge of 
the liver can be felt just below the ribs. I have outlined this edge in black. There appears 
to be no tenderness of the bones or enlargement of the epiphyses such as would occur in 
rhachitis, and there is no evidence of syphilis. The following examination of the blood 
has just been made by Dr. Wentworth : 



THE BLOOD IN INFANCY AND CHILDHOOD. 363 

BLOOD EXAMINATION 9. (Wentworth.) 

Erythrocytes 1,311,250 

Haemoglobin 20 per cent. 

Leucocytes 116,500 

Small mononuclear 46 per cent. 

Large " 34 " 

Polynuclear 16 " 

Eosinophiles 4 " 

A drop of the blood, you see, is watery and of a pale red color, but the corpuscles 
themselves you will observe on this slide under the microscope are not markedly pale. The 
erythrocytes vary much in size and shape, poikilocytes, microcytes^ and ynaci^ocytes all being 
present. In fact, the polymorphous character of the blood is very pronounced, the normo- 
blast type of the erythrocytes predominating. Mitoses are very frequent, and show all varie- 
ties of subdivision, many of the erythrocytes having two nuclei, others, being in process of 
subdivision, showing three and four segments. Many of the nuclei also lie eccentrically in 
the cells. The leucocytes are very variable in this case, but the mononuclear type prevails. 
The eosinophiles are relatively and absolutely increased, but are somewhat smaller than 
usual, and are polynuclear. 

(The infant failed rapidly and died. No autopsy was obtained.) 

Mv third case in the series is one in which the blood examination was so 
unsatisfactory that there is a possibility of my being mistaken in my opinion 
that it should be placed under the heading of anaemia infantum pseudo- 
leuksemica. It would seem^ however, from the history, and from the physical 
examination, that it can better be considered a case of this disease than of 
secondary anaemia. 

A male infant (Case 124), twelve months old, entered the hospital August 15, with 
the following history. The mother was healthy, the father was said to be tubercular. 
There were three other living children said to be healthy, and one child, a boy seven years 
old, was said to have died from some disease of the brain. The infant was healthy at 
birth, was nursed by its mother and throve until it was five months old, when patent foods 
of various kinds were given to it, and it was nursed irregularly. It then began to have di- 
gestive disturbances. On examination it presented so typical a picture of the two cases 
(Cases 122, 123) which I have just described as representing anjsmia infantum pseudo- 
leukgemica that I have had this colored sketch made of it. (Plate Y., facing page 830.) 
You will notice the intense pallor of the entire skin, which has the "waxen'" color in a 
pronounced degree. The transparent ears are very noticeable, and, as you see, I have 
mapped out the border of the enlarged spleen in black. The inguinal glands were slightly 
enlarged, and the liver was scarcely perceptible beneath the margin of the ribs, but the 
spleen was enormously enlarged, extending down into the left inguinal region as far as the 
crest of the ilium. There were no other enlarged glands detected. The abdomen was 
rather distended, and the infant was not especially emaciated. It had had convulsions 
from time to time since it was five months old. There was no evidence of rhachitis or 
of syphilis. An analysis of the mother's milk made on August 25 was as follows : 

ANALYSIS 56. 

Fat 191 

Milk-sugar G.45 

Proteids 2.66 

Mineral matter 01" 

Total solids 11.19 

Water _??l^^ 

100.00 



364 PEDIATRICS. 

The examination of the blood gave the following results : 

BLOOD EXAMINATION 10. (Whitney and Went worth.) 

I. August 25. II. October 17. III. November 9. IV. December 19. 

I. Erythrocytes 1,585,000 

(All of large size and normal red color.) 

Hsemoglobin ' 30 per cent. 

Leucocytes . . (The estimate was too doubtful and unsatisfactory to report.) 

Small mononuclear 61 per cent. 

Large " 23 " 

Polynuclear 14 " 

Eosinophiles • 2 " 

Megaloblasts and normoblasts in moderate numbers. 

II. Erythrocytes 3,215,000 

Hemoglobin 46 per cent. 

III. Erythrocytes 3,300,000 

Hiemoglobin 45 per cent. 

Leucocytes 

Small mononuclear 58 " 

Large " 45 " 

Polynuclear 8 " 

Eosinophiles , . 8 " 

IV. Erythrocytes 3,925,000 

Hsemoglobin 40 per cent. 

(Treatment of various kinds, both medicinal and dietetic, appeared to have no effect 
upon the patient's general condition, and when last heard from it was growing progressively 
weaker and more anaemic. ) 

I am fully aware that without the count of the total leucocytes the diagnosis is not 
proved. There should have been found a decided leucocytosis, which I shall assume to 
have been the case, as all the other characteristics of the disease were present. 

The fourth case which I shall speak of as one of ansemia infantum 
pseudo-leuksemica occurred some years ago in my practice, and, as no reli- 
able examination of the blood was made, I cannot, of course, accept the 
diagnosis as proved. It was, however, so interesting that it is well to put 
it on record, as it may in the future be valuable in comparison with cases 
having similar clinical symptoms, especially as an autopsy was obtained. 

The infant (Case 125), a male, was first seen and examined by me when it was four 
months old. The parents were healthy, and there was one older child, also healthy. 
There was no history of hereditary disease in the family. Their home was in a comfortable 
country house, well built, with good drainage, an unpolluted water-supply, and no arsenic 
in the papers, curtains, or furniture-coverings. The house was built on a considerable ele- 
vation, and was not in a malarial district. The infant was healthy at birth, and weighed 
3750 grammes {^\ pounds) ; it was nursed for a short time, and was then fed with various 
artificial foods. It soon began to show digestive disturbance and to grow pale. It lost 
somewhat in weight, had a gradually lessening appetite, and at times vomited. 

On physical examination nothing abnormal was found in the thorax or abdomen. 
There were no enlarged glands. The symptoms were entirely those of functional indiges- 
tion, and under a proper regulation of the diet it improved somewhat for a time, and there 
was a gain in weight. 



THE BLOOD IN INFANCY AND CHILDHOOD. 365 

Two months later I again saw the infant, and, with the exception that the pallor of the 
skin had much increased, nothing ahnormal was discovered. The infant was brought to 
the Children's Hospital to be under my care when it was eight months old. I then found 
that it had a much enlarged spleen. The liver and lymph-glands were not enlarged. 
There was a slight albuminuria. The erythrocytes were reported to be diminished and the 
leucocytes increased. Its weight was 6704 grammes (14| pounds). A few hemorrhagic 
spots were reported to have been seen on its legs and thorax before entering the hospital, 
but they were not present on entrance. The infant began to tail soon after coming to the 
hospital, and died a week later, the spleen having decreased in size. On the day of its 
death it became very restless and cried a great deal, putting its hands to its head. Nothing 
abnormal was found on examination of the ears. Slight oedema was detected at the base 
of both lungs a few hours before death, and it finally died rather suddenly. The follow- 
ing is the report of the autopsy made by Dr. W. F. Whitney : 

The body was that of an apparently well-nourished infant, and externally the only 
remarkable feature was the extreme pallor. 

The lungs were normal and retracted. 

The heart was of normal size and shape and without any malformation. A micro- 
scopic section showed an occasional granular fibre. The spleen was slightly enlarged, firm, 
and somewhat pale. Microscopic examination failed to show any deviation from the normal 
structure. The stomach and intestines presented nothing abnormal. The liver was of 
normal size, its consistency was firm, and its appearance was marked on section by a pale 
whitish color, which was everywhere present, and had no relation to any part of the 
lobules. Microscopic examination showed that the liver-cells were separated by large 
spaces, looking at first like dilated capillaries, filled with small cells similar to leucocytes. 
The appearance was very similar to that of a foetal liver of the fifth month. Chemical 
tests failed to show the presence of any free iron in the liver-cells. The kidneys and other 
organs presented nothing abnormal. 



Secondary Anemias. — The secondary ansemias are so numerous and 
arise from so many different causes that an exhaustive discussion of them 
T^ould hardly be practicable in a clinical lecture. You must bear in mind 
what I have already said regarding them : first, that almost every anaemia 
which we meet with is secondary, — that is, that it arises somewhere outside 
of the blood-making organs ; second, that in almost every disease of any 
organ a secondary anaemia is liable to arise, and is of a high or a low grade 
according to the severity of the disease. The changes in the form-elements 
of the blood which are found in these secondary conditions are simply the 
-constant occurrence of oligocythsemia and oligochromsemia, the presence or 
absence of leucocytosis, and the absence of the other characteristics which 
are supposed to belong to chlorosis, anaemia perniciosa, and anaemia infantum 
pseudo-leukaemica von Jaksch. Where the leucocytosis is great, the auivmia 
is usually one of the graver forms, and in these grave anaemias the leuco- 
cytes are found to vary from 14,000 to 54,000. You may remember this 
infant (Case 126, page 366), four months old, which I examined before you 
in the wards of the Infants' Hospital six weeks ago. It represented at that 
time what I shall later describe to you as a moderate grade of infnntlle 
atrophy. It was much emaciated, and the interference with the normal 
activity of the intestinal absorbents was seriously affecting its nutrition. It 
was pale, but did not have the " waxen'' pallor which I have described in 
previous cases. 



366 PEDIATRICS. 

A blood examination at that time gave the following result, which was 
simply that of a moderate grade of anaemia : 

BLOOD EXAMINATION 11. (Wentworth.) 

Erythrocytes 3,006,250 

Haemoglobin 40 per cent. 

Leucocytes 11,500 

The treatment was by food adapted to the disabled condition of the 
absorbents, — namely, a low percentage of fat with a rather high percentage 
of sugar and a moderately high percentage of proteids. You see what a 
marked change has occurred in the appearance of the infant, which has 
grown fat and is no longer anaemic. 

Case 126. 




Male, 4 months old. Infantile atrophy of medium grade, with moderate ansemia. 

TREATMENT. — With the exception of the case last spoken of, you 
will notice that up to the present time I have said nothing whatever as to 
the treatment of these diseases of the blood. I have done this purposely in 
order to impress upon you that in infants and young children these diseases 
depend, so far as I can ascertain, almost entirely upon some interference 
with the nutrition. It is very rarely that I give drugs in any form in these 
diseases. The treatment of anaemia perniciosa and anaemia infantum pseudo- 
leuksemica von Jaksch, either with or without iron, arsenic, or other drugs, 
is well known to be ineifectual. On the other hand, the treatment of 
chlorosis and the secondary anaemias has, in my experience, been followed 
usually by complete recovery. This treatment has been, first, to remove 
the cause, whether it be the inhalation or ingestion of poisons, such as 
arsenic or impure air and improper food ; second, to adapt the percentages 
of the food so as to meet the requirements of the special disease or results of 
that disease, in order that the infant's nutrition may be thus restored to a 
state of equilibrium, and the effects of the disease may be eradicated. From 
this stand-point you will understand that it would be impracticable to enter 
into the subject of treatment in detail in speaking of the blood as a whole. 



THE BLOOD IN INFANCY AND CHILDHOOD. 367 

The treatment of all these diseases of the blood is merely that of the especial 
disease which causes the blood-changes, and, as I have just said, is well 
illustrated by the treatment of this case (Case 126) of anaemia secondary to 
infantile atrophy. If you thoroughly understand the principle which under- 
lies the treatment and subsequent recovery of this case, you will appreciate 
the truth of what I have just said, and will be prepared to treat intelli- 
gently all the cases which I have already described to you. 

The more severe types of secondary anaemia are of great interest and 
importance in the study of infants and of children. As the grade of the 
anaemia becomes higher the specific gravity of the blood becomes somewhat 
lower. In addition to this there is more variation in the size and shape of 
the erythrocytes. There is poikilocytosis and microcytosis. A few nucleated 
erythrocytes, generally of the normoblast type, are found. They are, how- 
ever, not very numerous. The same causes give rise to these grave forms 
as to the milder forms of anaemia. The terms ^'syphilitic anaemia" and 
'^rhachitic anaemia" are misnomers, as there are no characteristic blood- 
changes in these anaemias. 

CONGENITAL SYPHILIS, WITH ENLARGED SPLEEN.— I will 
now show you a case of congenital syphilis which has been under my care 
for some time, and in which a number of careful blood examinations have 
been made. It represents very well the grave secondary anaemia which at 
times accompanies syphilis ; but, as I have already told you, these examina- 
tions of the blood show nothing characteristic of syphilis, but merely an 
ordinary secondary anaemia. 

This infant (Case 127) is three months old, and is being nursed by its mother. 

Case 127. 




Male, 3 months old. Congenital syphilis. Grave secondan- anamia. l.ower bonU'r ol rit-- 

enlarged spleen marked in black. 

It was healthy at birth, and remained so until it was three weeks old, when it showed 
marked syphilitic lesions, which have since become very characteristic. I shall not here 
enter into a full description of the case, as I shall show it to you again in a few days in 
connection with some other cases illustrating my lecture on congenital syphilis. The infant, 



368 PEDIATRICS. 

as you see, is fairly well nourished. You will notice the " waxen" pallor of the skin, so 
characteristic of the higher grades of grave anaemias. There is a moderate enlargement of 
the liver, which on palpation is found to be hard and somewhat tender. The inguinal 
glands are slightly enlarged. The post-aural glands are enlarged. The spleen is much 
enlarged, and extends, as I have indicated with the black line, from the fifth rib to the left 
inguinal region. It has, as you see, a peculiar tongue-shaped outline. It is hard, but is 
not tender. I can detect no other glandular enlargements. The examination of the blood 
gives the following results : 

BLOOD EXAMINATION 12. (Wentworth.) 

Nov. 17. Nov. 20. 

Erythrocytes 3,387,000 3,300,000 

Haemoglobin 47 per cent. 45 per cent. 

Leucocytes 20,000 20,000 

There is a considerable variation in the size of the erythrocytes, which are pale in color. 
There is poikilocytosis in a moderate degree ; there are also some microcytes and megalo- 
cytes. The mononuclear elements predominate (about three-quarters). The eosinophiles 
are not numerous. 

RHACHITIC ANEMIA. — Rhachitis is so commonly met in early 
life after the first six months, both alone and in connection with other 
diseases, that I think it Avill be well to tell you what is known about the 
blood before speaking of the separate blood examinations which I have had 
made in a number of different cases. In this class of cases there is a com- 
plete independence of the specific gravity, as influenced by the course of the 
disease, except when it is complicated by anaemia. When this occurs the 
specific gravity falls, and it invariably rises as recovery from the rhachitis 
takes place. Unless this disease is accompanied by a secondary anaemia, 
the blood is practically normal. Hock and Schlesinger found that if the 
secondary anaemia was moderate in intensity, and diarrhoea and vomiting 
occurred, it simply made the anaemia more acute. The majority of the 
leucocytes were found to be mononuclear and about the size of the erythro- 
cytes. There is a moderate permanent leucocytosis in most of these cases, 
and at times the mononuclear leucocytes seem to be the most numerous form. 

Rhachitic Anemia without Splenic Enlargement. — This infant 
(Case 128), a female, seven months and three weeks old, has just been 
brought to the hospital for treatment. The enlarged epiphyses of the wrists 
and ankles, the rhachitic rosary, and the other symptoms which so com- 
monly occur in infants fed on patent foods, indicate that this is a case of 
moderate rhachitis. The infant is pale and poorly nourished. The blood 
examination gives the following result : 

BLOOD EXAMINATION 13. (Whitney and Wentworth.) 

Erythrocytes . 4,492,000 (occasionally nucleated) 

Hsemoglobin 70 per cent. 

Leucocytes 22,000 

Small mononuclear 33 per cent. 

Large " 32 " 

Polynuclear 35 <' 



THE BLOOD IX INFANCY AND CHILDHOOD. 



369 



Ehachitic Anemia with Splenic Enlargement. — This case, 
which I have under treatment in the wards, is a very interesting illus- 
tration of rhachitis with a secondary anaemia of high grade, accompanied 
by enlargement of the spleen. 

The child is three years old, and, as you see, is fairly well nourished. (Case 129.) 

Case 129. 




3Iale, 3 years old. KhacMtis, with enlarged spleen. 

It has, however, enlarged epiphyses, a rhachitic rosary, the square rhachitic head, and 
marked howing of the legs. On physical examination I find no indication of enlargement 
of the liver or glands. The spleen is very much enlarged, and I have indicated the posi- 
tion of its outline and its notch, as you see, in black. The blood examination has just been, 
made, and gives the following figures : 

BLOOD EXAMINATIONS^ 14. (Wentworth.) 

Erythrocytes 2,686,250 

Haemoglobin 35 per cent. 

Leucocytes 13,000 

Poikilocytes and marked pallor of the corpuscles were present. 



24 



370 PEDIATRICS. 



LKCTURK XVI. 

THE BLOOD IN INDIVIDUAL DISEASES. 

Typhoid Fever — Scarlet Fever — Measles — Variola — Diphtheria — Pneumonia — 
Broncho-Pneumonia — Pneumonia and Empyema — Empyema — Miliary Tuber- 
culosis — Tubercular Meningitis — Hydrocephalus — Chorea — Nephritis — 
Tubercular Peritonitis — Infantile Atrophy — Periostitis — Scorbutus — Ic- 
terus Neonatorum — Sclerema Neonatorum. 

A NUMBER of observations have been made on the blood of children 
where a condition of fever was present, and a few regarding the specific 
gravity of the blood in connection with a heightened temperature. 

Widowitz found in five-eighths of the cases examined during fever that 
the haemoglobin was higher than in the post-febrile period. The remaining 
three-eighths of the cases had other complications. Regarding the diminu- 
tion in the number of erythrocytes and the percentage of haemoglobin after 
fever, he explains it either as an actual diminution of hsemoglobin or a 
dilution of the blood by absorption of fluid from the tissues. 

Schiif, who has made the most reliable and methodical experiments on 
this subject, differs from Widowitz in some points. He found a diminution 
of erythrocytes during the fever and an increase afterwards, and in long- 
continued fever this was modified somewhat, so that the absolute count was 
lower. This he considers due to a diminished production, and so a condi- 
tion of anaemia is gradually produced. He considers the diminution of the 
erythrocytes in acute fever to be partially due to an increased degeneration 
of the red corpuscles, and also to the increased metabolism, and not to 
diminished production. He could not perceive any connection between the 
normal daily variation of the temperature and the blood-count. He found 
that the haemoglobin was diminished at the beginning of the fever, together 
with the red corpuscles, but that later it was even more marked than the 
diminution of the red corpuscles, especially when the fever was long 
continued. He noted cases in which the red corpuscles increased later, but 
the haemoglobin remained diminished, or even sank lower. 

Regarding the leucocytes in fever, SchifP considers that they do not 
follow the course of the fever, as regards increase and diminution, except at 
the beginning, when there is an increase. Some other authors consider that 
the leucocyte count is not affected by the temperature alone, but that when 
fever is accompanied by local suppuration the leucocytosis is much more 
marked. This agrees with the results obtained in adults. 

I shall now show you a number of cases in the wards representing dif- 
ferent diseases, in each of which a blood examination has been made lately. 

TYPHOID FEVER. — Arnheim found a striking diminution in the 



THE BLOOD IN INFANCY AND CHILDHOOD. 371 

amount of haemoglobin after defervescence had occm-red, and in spite of an 
increase in the number of the erythrocytes. In this disease we know that 
the leucocytes are usually diminished in number. This also occurs in 
malaria. In the early stages the erythrocytes are increased, as is also the 
haemoglobin. In the later stages a condition of anaemia may occur, pro- 
ducing a diminution of the red corpuscles and haemoglobin. 

Here is a girl, eight years old (Case 130), with the clinical symptoms of typhoid fever. 
The examination of the blood gives the following result : 

BLOOD EXAMINATION 15. (Wentworth.) 

Erythrocytes 4,602,500 

Hsemoglobin 60 per cent. 

Leucocytes 7,000 

The next case (Case 131) is also one of typhoid fever, in a boy six years old, and the 
result of the blood examination is as follows : 

BLOOD EXAMINATION 16. (Whitney and Wentworth.) 

Erythrocytes 5,496,250 

Hsemoglobin 64 per cent. 

Leucocytes 7,000 

Small mononuclear 14 per cent. 

Large " 20 " 

Polynuclear 66 " 

As I shall not take you into the contagious wards this morning, I think 
it will be well, before passing on to the other patients, to remind you in a 
few words of what we should be likely to find on examining the blood of 
children with scarlet fever, measles, variola, or diphtheria. 

SCARLET FEVER. — Widowitz divides the cases of scarlet fever 
systematically into three groups : a, those with a mild course and without 
complications ; 6, those in which nephritis occurs as a complication ; and c, 
those with a malignant course. All three from the beginning showed a 
high percentage of haemoglobin, which in uncomplicated cases diminished 
with the disease, and rose again later without reaching the former high 
percentage. In the cases of nephritis there was a rapid fall of the haemo- 
globin. The malignant cases showed no constant relation. As above 
mentioned, leucocytosis was generally present, even in the stage of incuba- 
tion. 

MEASLES. — Arnheim found in uncomplicated cases no especial 
changes in the haemoglobin. He found slight variations, but less than in 
scarlet fever, and in convalescence the haemoglobin often reached the high 
percentage found in the efflorescent stage of the disease. Von Limbeck, 
Pick, and Rieder found no leucocytosis in uncomplicated cases of measles, 
and thought this fact of value in the diagnosis from scarlet fever. 

VARIOLA. — Arnheim found the haemoglobin diminished at the begin- 
ning of the disease. After the formation of pustules and during their exsic- 



372 PEDIATEICS. 

cation, he found an increase of the haemoglobin, with diminution of the 
erythrocytes. Where complicating suppuration occurred, both the erythro- 
cytes and the haemoglobin remained for a long time abnormally diminished. 

Hayem found in '^ variola confluens'^ that the erythrocytes were dimin- 
ished to two million ; in the stage of eruption they were normal, and in the 
stage of suppuration, in consequence of the concentration of the blood, they 
were increased. Two weeks after the fall of the temperature they were 
normal. 

R. Pick reports forty-two cases examined by him in which he found 
no leucocytosis, except in the stage of suppuration or in some complication 
like pneumonia. The temperature, the severity of the disease, or even a 
fatal termination, unless complicated as above, produced no leucocytosis. 

DIPHTHERIA. — Bouchut and Dubrisay found in severe septicaemic 
forms of diphtheria an increase of leucocytes, increasing and diminishing 
with the severity of the process. The mild cases showed no leucocytosis, 
which fact, according to these authors, has a prognostic value. Von Lim- 
beck found always a marked leucocytosis, and it was greatest in the severest 
cases. 

PNEUMONIA. — The leucocytosis is generally very marked, coming 
on from six to twelve hours before the physical signs of pneumonia 
show themselves, and in the same way the temperature crisis of the pneu- 
monia is sometimes preceded by a crisis in the number of the leucoc}i»s 
of about the same length of time. This, of course, is of value in prog- 
nosis. There have been some cases recorded (generally fatal ones) in which 
the leucocytosis did not occur. This may possibly have been dependent upon 
the nature of the infection. Yon Limbeck's experiments upon dogs seem 
to show that Friedlander's bacillus caused a marked leucocytosis, whereas 
Fraenkel's diplococcus caused scarcely any. The leucocytosis is said to be 
higher in children than in adults in pneumonia. 

Here in this next bed (Case 132) is an infant eight months old with the characteristic 
clinical symptoms and physical signs of a fibrinous pneumonia, involving the whole of the 
left lower lobe of the lung. As the case is one of undoubted pneumonia without compli- 
cations, the blood examination which has just been made is of unusual interest : 

BLOOD EXAMINATION 17. (Whitney and Wentworth.) 

Erythrocytes 4,813,750 

Haemoglobin 54 per cent. 

Leucocytes 40,000 

Small mononuclear 51 pgp cent. 

Large " 21 " 

Poly nuclear 27 " 

Eosinophiles 1 a 

The small percentage of the polynuclear cells is very unusual in a case of this kind. 
They are generally much increased, and their small percentage, though partially accounted 
for by the age of the infant, cannot be entirely explained in this way. 

The next case that I have to show you (Case 133) is also one of pure fibrinous pneu- 



THE BLOOD IN INFANCY AND CHILDHOOD. 373 

monia, in a boy three and one-half years old. Three examinations of the blood have been 
made in this case. The first one was made eighteen hours after the crisis had occurred 
the second one forty-five hours after the crisis, and the third one has just been made to- 
day, which is the tenth day since the crisis occurred. 

BLOOD EXAMINATION 18. (Whitney and Wentworth.) 
{After crisis.) 

L n. m. 

18 hours. 45 hours. 10 days. 

Erythrocytes . . 4,598,750 4,849,166 About the same as before. 

Haemoglobin . , 52 per cent. 53 per cent. Not taken. 

Leucocytes . . 24,500 29,000 17,500 

Small mononuclear .... 28 per cent. 21 per cent. 

Large " .... 18 " 11 " 

Polynuclear 51 " 68 " 

Eosinophiles 3 " 

At the time that the second examination was made the temperature was normal. The 
percentage of polynuclear cells in this case would be very small if the patient were an adult, 
but for a child of this age they show, as would be expected, a moderate increase. To-day, 
with a normal temperature and with resolution completed, we find, as we should expect, a 
decided lessening of the leucocytosis. Dr. Cabot's observations have convinced him that 
the so-called blood crisis occurs in only a certain percentage of cases of pneumonia, and 
that a blood lysis is more common. 

BRONCHO-PNEUMONIA.— The next case (Case 134) is one of broncho-pneu- 
monia occurring in a rhachitic child four years old. 

BLOOD EXAMINATION 19. (Whitney and Wentworth.) 

Erythrocytes 4,286,250 

Haemoglobin 53 per cent. 

Leucocytes 54,000 

Small mononuclear 18 per cent. 

Large " 11 " 

Polynuclear 71 " 

The pneumonia was marked by certain circumscribed patches of dulness in both backs. 
It ran the usual course of broncho-pneumonia, and resulted in complete recovery. 

PNEUMONIA AND EMPYEMA.— The next case (Case 135) is that of a boy 
thirteen years old, who has had a marked fibrinous pneumonia running its usual course, 
and now has an empyema as a complication. He has been aspirated, and streptococci were 
found in the pus. The result of the blood examination is very significant. 

BLOOD EXAMINATION 20. (Whitney and Wentworth.) 

Erythrocytes 3,513,750 

Haemoglobin 43 per cent. 

Leucocytes 45,000 

Small mononuclear 8 per cent. 

Large " 5 " 

Polynuclear 86 " 

Eosinophiles 1 " 

On comparing this case with the two cases of fibrinous pneumonia which I have just 
shown you, you will note how much larger the percentage of polynuclear cells is than 
where the pneumonia was uncomplicated. 

EMPYEMA. — This next case (Case 136), a boy twenty months old, is one of 
empyema. The blood examination was made yesterday. 



374 PEDIATRICS. 

BLOOD EXAMINATION 21. (Whitney and Wentworth.) 

Erythrocytes 4,393,750 

Haemoglobin 49 per cent. 

Leucocytes 28,000 

SmaK mononuclear 9 per cent. 

Large ^ " 16 " 

Polynuclear 74 *' 

Eosinophiles 1 " 

(This infant had the radical operation for empyema performed on it, and ultimately 
recovered completely.) 

Here in this next bed is another case of empyema (Case 137), ten years old, in which 
the blood count was made this morning. 

BLOOD EXAMINATION 22. (Whitney and Wentworth.) 

Erythrocytes 4,355,000 

Haemoglobin 60 per cent. 

Leucocytes 66,000 

Small mononuclear 7 per cent. 

Large " 8 " 

Polynuclear 85 " 

(This child was operated upon and recovered completely.) 

MILIARY TUBERCULOSIS.— You will remember the male infant twenty- 
five months old (Case 138) which I examined before you in the ward yesterday, and in which 
there was a question whether it was a case of simple starvation or one of general miliary 
tuberculosis with some complication. The blood examination resulted as follows : 

BLOOD EXAMINATION 23. (Whitney and Wentworth.) 

Erythrocytes 5,567,500 

Haemoglobin 66 per cent. 

Leucocytes 29,500 

The autopsy this morning showed a general miliary tuberculosis of all the organs, and 
an absence of pneumonia. 

Miliary tuberculosis in adults shows no leucocytosis, and the increase of the leucocytes 
in this case is but moderate, and might be due entirely to starvation. 

TUBERCULAR MENINGITIS.— Here is an interesting case of cerebral disease 
(Case 139) in a male infant. The clinical symptoms and general aspect of the child are 
those of tubercular meningitis. The blood examination, however, shows that some com- 
plication is in all probability present. 

BLOOD EXAMINATION 24. (Whitney and Wentworth.) 

Erythrocytes 4,541,250 

Haemoglobin 68 per cent. 

Leucocytes 38,000 

Small mononuclear 22 per cent. 

Large " 20 " 

Polynuclear 58 " 

In considering this case I must remind you that the bacillus of tuberculosis is not a 
pyogenic organism. As I can find no lesion in any of the organs to account for the 
increase in the leucocytes, a large proportion of which are polynuclear neutrophiles, we 



THE BLOOD IN INFANCY AND CHILDHOOD. 375 

must suppose that the original miliary inflammation was followed by a secondary infection 
of some pus-producing organism. 

(The infant passed through the various typical stages of tubercular meningitis and 
died. No autopsy was obtained.) 

The statement that the leucocytosis which is at times found in tubercular meningitis 
depends on some complication is well illustrated in the case (Case 140) of the little girl 
eleven years old who was shown to you a few days ago as a case of tubercular meningitis. 
The clinical symptoms were very typical from the beginning to the end of the disease, but 
the blood examination, as 1 explained to you at that time, led me to believe that some 
complication was present. 

BLOOD EXAMINATION 25. (Wentworth.) 

Erythrocytes 5,298,750 

Haemoglobin 68 per cent. 

Leucocytes 37,500 

The autopsy showed the case to be one of tubercular meningitis, represented by solitary 
tubercles in the brain without any purulent exudation. There was, however, found in the 
abdomen an appendicitis, which accounted for the leucocytosis. 

HYDROCEPHALUS.— This little girl (Case 141), six years old, is a marked case 
of hydrocephalus. The history of the noticeable enlargement of the head corresponds to 
the general hydrocephalic appearance of the child. 



Case 141. 





In the result of the blood examination of this case I cannot explain the high per- 
centage of the poly nuclear cells. 

BLOOD EXAMINATION 26. (Whitney and Wentworth.) 

Erythrocytes 5.675,000 

Hs^moglobin 80 per cent. 

Leucocytes 19,000 

Small mononuclear 4 per cent. 

Large " ^ 

Polynuclear ^^ 

Eosinophiles ^ 

This next case (Case 142), a boy two years and ten months old. is apparently also one 
of hydrocephalus, but of slight degree. The blood examination resulted n< t'.'ll.>w> : 



376 PEDIATRICS. 

BLOOD EXAMINATION 27. (Whitney and Wentworth.) 

Erythrocytes 4,492,500 

Haemoglobin 72 per cent. 

Leucocytes 20,500 

Small mononuclear 20 per cent. 

Large " 20 " 

Polynuclear 58 " 

Eosinophiles 2 " 

The cause of this leucocytosis is not known. The examination of the lungs and the heart 
was negative ; the head measured twenty-six inches ; there was protrusion of the eyes, as 
well as mental disturbance. The child remained in the hospital, and showed continued 
improvement until complete recovery some months later. 

CHOREA. — I shall now show you a case (Case 148) of chorea of a severe type, but 
without complications. The child, a boy eight years of age, can scarcely swallow, and is 
unable to speak, stand, or walk. The choreiform movements are, as you see, constant. 
The result of the blood examination is as follows : 

BLOOD EXAMINATION 28. (Wentworth.) 

Erythrocytes 5,222,500 

Haemoglobin 60 per cent. 

Leucocytes 19,000 

There has at times been a faint hsemic murmur over the base of the heart, but this has 
been very transient and has now passed away. 

NEPHRITIS. — I have here to show you two cases (Cases 144, 145) of renal disease. 
The examinations of blood made in renal disease in children have not been very extensive 
or satisfactory, but in general the specific gravity of the blood is quite low, on account of 
the loss of albumin in the blood serum. The specific gravity of the serum is much dimin- 
ished, 1022 to 1023. Klein, in a series of observations upon the blood in the nephritis 
of scarlet fever, has found an increase of eosinophiles in favorable cases, and an absence of 
them in fatal cases. 

Acute Nephritis. — This first case (Case 144), a boy six years old, was one of 
acute nephritis. The urine at present, however, only shows an active hypersemia of the 
kidney. The blood examination gives the following results : 

BLOOD EXAMINATION 29. (Whitney and Wentworth.) 

Erythrocytes 3,481,250 

Haemoglobin 51 per cent. 

Leucocytes 32,500 

Small mononuclear 8 per cent. 

Large " 10 " 

Polynuclear 80 " 

Eosinophiles 2 " 

The percentage of the eosinophiles, you see, is no greater than normal, although the 
case seems to be tending towards recovery. 

Chronic Nephritis. — The other case (Case 145), a girl nine and one-half years 
old, is one of chronic parenchymatous nephritis. 

BLOOD EXAMINATION 30. (Whitney and Wentworth.) 

Erythrocytes 4,355,000 

Haemoglobin 60 per cent. 

Leucocytes 33,000 

Small mononuclear 36 per cent. 

Large " 4 " 

Polynuclear 60 " 



THE BLOOD IN INFANCY AND CHILDHOOD. 377 

Unfortunately, the percentage of eosinophiles in this case was not recorded. The size 
of the leucocyte count is remarkable. 

TUBERCULAR PERITONITIS.— I have here two cases of tubercular peri- 
tonitis, in which the diagnosis has been -verified by laparotomy. The blood examinations 
were made before the operations were performed. 

The first case (Case 146) was one of an infant eighteen months old, and the blood 
examination resulted as follows : 

BLOOD EXAMINATION 31. (Whitney and Wentworth.) 

Erythrocytes 4,970,000 

Haemoglobin 48 per cent. 

Leucocytes 19,000 

Small mononuclear 19 per cent. 

Large " 18 " 

Polynuclear 73 " 

This case, as well as the first one, followed the rule of an absence of leucocytosis in 
tuberculosis, for at this age the leucocyte count may be as high as 19,000 to 20,000 under 
physiological conditions. 

The second case (Case 147) is a boy nine years old. 

BLOOD EXAMINATION 32. (Whitney and Wentworth.) 

Erythrocytes 4,792,500 

Haemoglobin 65 per cent. 

Leucocytes 7,500 

Small mononuclear 18 per cent. 

Large " 31 " 

Polynuclear 54 " 

INFANTILE ATROPHY.— The next case (Case 148), eleven months old, is one 
of infantile atrophy. The extreme emaciation of this infant is well seen in looking at its 

Case 148. 




Infantile atrophy. Female, 11 months old. 

back, where there is an almost entire absence of adipose tissue, so that the vcrtebnv and the 
ribs can be studied as thous-h on the dissected skeleton. 



378 PEDIATEICS. 

The result of the blood examination in this case is as follows : 

BLOOD EXAMINATION 33. (Wentworth.) 

Erythrocytes 4,738,750 

Haemoglobin 76 per cent. 

Leucocytes 21,000 

This count was made after the infant had been under treatment for over three and a 
half months, so that we cannot take it as typical of the early stages of the disease. 

Guifer found a gradual diminution of erythrocytes and an increase in 
leucocytes in these cases of infantile atrophy, which he referred to the 
accompanying anaemia. Parrot found that a diminution of red corpuscles 
constantly went on until death, and that the increase in the leucocytes cor- 
responded to the severity of the disease. Schiff made some experiments 
proving the analogy between these cases with loss of fluid and cases in 
which fluids were withheld, both causing concentration of the blood. 

PERIOSTITIS. — In order to show you of what great importance a 
careful examination of the blood may be in determining the diagnosis in 
obscure cases, I will report to you the following case (Case 149) : 

Case 149. 




Female infant, 15 months old. Periostitis of both legs. 

Many of you will remember seeing the infant at the Children's Hospital, where it was 
brought to be treated for a persistent and painful swelling of the right thigh. It was 
at that time fifteen months old, and the pain had been so severe that it had lost much 



THE BLOOD IN INFANCY AND CHILDHOOD. 379 

sleep. The right thigh was swollen to nearly twice the size of the left one, and was very 
tense, — in fact, so much so that the outline of the bone could not be distinguished. The 
suffering of the infant was so great that it was transferred to the Infants' Hospital, where 
it came under the surgical care of Dr. Lovett. For the purpose of diagnosis an incision 
was made on the outer side of the right thigh. On reaching the bone, it was found to be 
covered with a layer of grayish, friable tissue, at least a quarter of an inch in thickness. 
The aspect of the growth was that of a malignant tumor, and this appearance was so 
striking that a small bit was removed and referred to a pathologist for examination. The 
report from this examination was that the growth removed was not large enough for a posi- 
tive diagnosis, but that it simulated very closely an osteo-sarcoma. A few days later 
another incision was made in the right tibia, which can be seen in this photograph taken 
immediately after the operation. 

Another piece of the growth was removed, and on examination was reported by the 
pathologist to be probably an osteo-sarcoma. The infant had been in the hospital for 
about ten days, and the swelling had steadily increased, while its general condition had 
become worse. The question of amputation was considered, but at this time a blood count 
was made, which so strongly pointed toward the absence of a malignant growth that it was 
considered wiser to postpone the operation and wait for further developments. 

BLOOD EXAMINATION 34. (Whitney.) 
Leucocytes. 

Small mononuclear 46 per cent. 

Large " 18 " 

Polynuclear 36 " 

The significance of this differentiation of the leucocytes lay in the small percentage of 
the polynuclear variety, which should have been found increased if the disease of the bone 
had been a new growth, such as is represented by osteo-sarcoma. Somewhat later, but 
before the blood examination had been finished, the left thigh was also incised, owing to a 
suspicion of trouble in that location, and a piece of periosteum covering the left femur was 
removed. This was also reported as a probable osteo-sarcoma, and the infant was dis- 
charged from the hospital as a hopeless case, and was taken home to die. The subsequent 
history of this case is of extreme interest, in reference to the value of blood examinations, 
for the infant soon began to improve, the swelling was absorbed, and, although the infant 
was late in walking, it is now, after an interval of some months, well and strong, and 
presents no appearance of disability in the legs. The growth was probably a sluggish 
periostitis of an unusual type, which simulated sarcoma very closely. The case is a 
unique one. 

SCORBUTUS. — Nothing distinctive has as yet been found in the blood 
examinations which have been made in cases of infantile scorbutus. 

ICTERUS NEONATORUM. — The simple benign form of icterus 
neonatorum, which I have described to you in an earlier lecture, is j)racti- 
cally a physiological condition. Up to the present time there have not been 
found any pathological changes in the blood. 

SCLEREMA NEONATORUM. — In the beginning of sclerema neona- 
torum there is no especial change in the blood until the tissues have been 
drained of their fluid. In protracted cases, however, through diminution 
of the haemoglobin, caused by insufficient fluid, a gradual sinking may 
occur in the specific gravity of the blood without any change in the serum. 



380 PEDIATRICS. 



L.KCTURK XVII. 

PARASITES OF THE BLOOD.— LITERATURE OF THE BLOOD IN 

EARLY LIFE. 

As in other parts of the economy, so in the blood are found parasites, 
which may be of the vegetable or of the animal kingdom. 

Of the vegetable parasites, such as (1) Moulds, (2) Yeasts (Saccharo- 
mycetes), and (3) Fission-fungi (Schizomycetes, Bacteria), the latter (Fission- 
fungi) are the only ones which would be likely to occur in the blood of 
early life, and even they do not especially concern us in our discussion of 
the blood. 

Of the animal parasites (Hsematozoa) we find two classes, (1) Protozoa 
and (2) Vermes. The former class (Protozoa) is the only one with which I 
have had any experience, and I shall therefore confine my remarks to the 
micro-organisms of malaria. 

MALARIA. — The term malaria should be limited to a definite disease 
in which we know there is a specific infectious origin. This specific infection 
is primarily shown in the blood in the form of certain micro-organisms 
which, like the amceba coli, belong to the class of protozoa, and inhabit 
the blood of the infected individual. We must, however, understand that 
in the specific micro-organisms of malaria we have not as yet proved the 
three conditions required to show that a given disease is caused by a specific 
micro-organism. These three conditions, as formulated by Koch, are as 
follows : 

(1) The presence of the organisms in all cases of the disease and in 
such distribution as will explain the lesions. 

(2) The isolation of the organism in pure culture. 

(3) The reproduction of the disease by inoculation with the isolated 
organisms. 

When, as has been said by Welch, all these conditions have been ful- 
filled, there will be no doubt that the disease has been caused by the especial 
organism. In regard to malaria, therefore, you see that only the first of 
Koch^s three required conditions is present. The micro-organism of malaria 
has not been found in any other part of the body than the blood, and 
malaria may therefore justly be said to be a disease of the blood. It has 
no known means of exit from the body, and its mode of entrance has not 
been definitely determined. The germs of this parasite may be contained 
in the blood-plasma, or in the substance of the erythrocytes. The name 
Plasmodium has been given to the germ found in the red blood-disks. 
According to Thompson, in acute paludism (malarial fever) the plasmodium 



THE BLOOD IN INFANCY AND CHILDHOOD. 381 

is foimd in the form of amoeboid bodies, occupying a place in a certain 
number of the erythrocytes or adhering to them. These bodies derive pig- 
ment (melanin) from the erythrocytes, and, after imdergoing a certain degree 
of development, increase in size at the expense of the erythrocytes. They 
are found to contain this pigment in distinct granules and rods. They 
vary in size, and some are as large as the erythrocytes. They are at 
first colorless and transparent, and at the height of their development 
they undergo segmentation. This amoeboid form of the parasite is the 
one commonly found in what is designated as the tertian varietv^ of mal- 
aria, and is the most common of all the known forms of the parasite of 
malaria. 

In addition to these amoeboid forms, crescentic shapes of the germ, 
according to the investigations of Laveran, are common in the blood of 
certain types of paludism, irregular forms of the disease, and malarial 
cachexia. Like the amoeboid forms, they are transparent and colorless, 
except for the pigment-granules which they contain in their centres. They 
are larger than the amoeboid forms, are much more rare, and are much less 
affected by the action of quinine. 

Coimcilman describes flagellate bodies as being most commonly found 
in blood which has been aspirated from the spleen ; and in acute cases of 
malaria they may sometimes appear in other situations. They exhibit from 
three to eight vibrating cilia. 

It is still a matter of dispute whether the plasmodium malarise is poly- 
morphous and thus may produce the different types of malaria, of which I 
shall presently speak, or whether there are certain distinctly separate organ- 
isms to which the name plasmodium malari£e is applied. 

There is no doubt that two distinct forms of parasites of malaria can be 
diagnosticated by the appearance of the plasmodium in the blood, and that 
these two forms can be separated clinically. 

Golgi is the investigator who has most clearly shown that there is more 
than one parasite of malaria, while Laveran is the exponent of the poly- 
morphous theory. 

Method of Examination. — The technique of the examination of 
the blood for the purpose of detecting the plasmodium malariae is very 
simple. I shall describe the method which has been used more largely 
for children than any other, and which has been found satisfactory by 
Dr. Koplik, of New York, whose work on the blood of malaria in early 
life is more extensive than that of any other investigator up to the present 
time. 

The blood is first examined in a fresh condition by placing a drop (Mi 
a slide, covering it with a cover-glass, and studying it under a microsoo[)e 
without a heated stage. Another specimen of blood is spread rapidly on a 
dozen or eighteen cover-slips by Ehrlich's method. The blood is then 
allowed to dry in the air, protected from dust. It is then plac^ on the 
Ehrlich brass plate and heated for an liour or an hour and a half. The 



382 PEDIATEICS. 

cover-glasses are then stained in a very dilute solution of methylene-blue. 
Eosin is not used, as some varieties decolorize the blue and thus intro- 
duce an element of uncertainty. The blood is heated at a temperature 
above the boiling-point (120° C.) on the plate. The variety of dye is 
important, as some blue does not stain. Griibler's blue powder, soluble 
in alcohol, has proved to be satisfactory. A few drops of the saturated 
solution of this blue in alcohol are added to 30 c.c. (1 ounce) of water. 
The cover-glasses should not be deeply stained, as certain appearances 
may, under these circumstances, be lost. They are to be repeatedly washed 
in water and then dried in the air without heating, as heat decolorizes 
them. In this way the blood-cell is well hardened, and its protoplasm 
and haemoglobin stain more certainly than when hardened with alcohol, 
sublimate, or osmic acid. Other specimens, again, may be stained by Ehr- 
lich's aniline method to study the different appearances. The erythrocytes 
of malarial cases, when stained in this way, show the plasmodium in blue 
and the protoplasm in yellowish green or colorless rings, if there is anaemia. 
If the Ehrlich dyes are used, aurantia, orange G, and others (preferably 
the solution in glycerin of eosin, indulin, and aurantia), the plasmodium 
does not stain, but the hsemoglobin of the erythrocytes is stained in shades 
of varying intensity. 

As in every case of pronounced malaria, whether in early life or in 
adults, the characteristic feature of the disease is a paroxysm, we naturally 
should first examine the blood at a time when this paroxysm is taking place, 
and from this point study the changes which the parasite shows in the inter- 
vals between the paroxysms. 

Golgi was the first observer who actually described and differentiated 
the more common forms of paludism, and his observations coincide practi- 
cally with those which have been made since. I shall, therefore, describe, 
as observed by Golgi, the main features of the changes in the blood which 
are caused by the development of the plasmodium, and such features as 
will explain the resulting symptoms of malaria and will thus be of clinical 
importance. These changes in the plasmodium have been so well de- 
scribed by Dr. Thayer, of Baltimore, that I shall quote what has been 
said by this admirable investigator. It will, however, be necessary first 
to explain certain terms which, having been used in connection with mal- 
aria, and having become established before the specific parasite of malaria 
was known, are really more adapted to the symptoms of the disease, and 
are hence given more prominence than is in accordance with our present 
knowledge of it. 

The prominent symptom of malaria being the paroxysm, earlier authors 
naturally classified malaria according to the time when the paroxysms ap- 
peared, using the term quotidian where they occurred with intervals of 
twenty-four hours, tertian where they occurred with intervals of forty-eight 
hours, and quartan where they occurred with intervals of seventy-two 
hours. The term tertian is somewhat misleading, unless we understand 



THE BLOOD IN IXFANCY AND CHILDHOOD. 383 

that it is a word derived from the Latin method of counting the day 
of the beginning of the febrile manifestation as the first day. The terms 
tertian and quartan, therefore, are simply used empirically to represent 
intervals of forty-eight and of seventy-two hours between the paroxysms. 
Again, the terms intermittent and remittent have been used commonly. 
The intermittent form is characterized by entire absence of fever bet\^'een 
the paroxysms. The remittent form is characterized by the presence of 
more or less fever of a continued type which does not cease between the 
paroxysms. You will presently see that these terms should not be used as 
classifications of distinct types of malaria, as the conditions which they rep- 
resent may, according to chance, appear in any of the t)'pes, and are merely 
caused by a variation in the behavior of the parasite. 

If we examine the blood from a tertian case where there is a decided 
interval of twenty-four hours bet^'een the paroxysms, we find that just 
after the paroxysm some of the erythrocytes will contain small, round, 
colorless bodies, which appear to have a slight depression in the centre, 
and when stained in dry specimens show a pale central area with a dark 
periphery. 

^^ These bodies, examined in the fresh specimen, show active amoeboid 
movements. A few hours later the organism will be found to have in- 
creased somewhat in size and to contain a few fine brownish pigment- 
granules which dance actively under the eye, the motion probably being 
due to undulating movements in the protoplasm. On the day betsveen the 
paroxysms the bodies will be found to have half filled the erythroc}i:es. 
They are still actively amoeboid, and the number of pigment-granules is 
considerably increased. The erythrocyte at this stage will be seen to be a 
trifle larger than its unaffected neighbors, and to be considerably decolorized. 
On the day of the paroxysm the organism is found to have entirely filled 
and almost to have destroyed the erythrocyte, which is represented only by 
a faint pale rim about the full-grown parasite, if indeed it has not entirely 
disappeared. The pigment-granules may show at this stage a very active 
motion, but the amoeboid movements of the organism, as a whole, are but 
little marked. At the time of the paroxysm a change takes place. The 
pigment gathers together in a more or less solid clump, usually in the 
centre of the erythrocyte, while the rest of the protoplasm looks somewhat 
granular, and shows a suggestion of lines radiating outward from the 
centre. This appearance gradually changes, the lines becoming more dis- 
tinct, until finally we see the central clump of pigment surrounded by from 
fifteen to twenty small, ovoid or round glistening segments, each one having 
a central more refractive spot, and resembling strongly the liy aline Ixxlios 
which w^e see immediately following the chill. This segmentatic^n of the 
organism is always coincident with the paroxysm, and the presence in the 
blood of a segmenting body is a sure indication that the })aroxysm is }irt\<ent 
or is about to occm\ Immediately folloAving the paroxysm fi-esh hyaline 
bodies appear in the erythrocytes. Though the invasion of the corpuscles 



384 PEDIATRICS. 

by these fresh segments has never been actually observed, the evidence that 
this occurs is so strong that we can safely accept it as a fact. Besides these 
forms, we see not infrequently small or large extra-cellular pigment bodies, 
— that is, organisms resembling exactly those within the erythrocytes, 
except that they are free in the blood-current. These may be seen at times 
to break up into several smaller bodies, while at other times they may show 
a long tail-like non-motile process containing sometimes a few pigment- 
granules. They are probably organisms which have escaped from the ery- 
throcytes, or full-grown bodies which have broken up. They are considered 
to be a degenerative form." 

At times we find the flagellate bodies which I have already referred to 
as described by Councilman. 

According to Thayer, the characteristics of this form of organism, 
which is observed in tertian fever alone, are so marked that with a little 
study of the parasites one can make a definite diagnosis of the type of fever 
from an examination of the blood alone. He also observes that the quartan 
fever is not common in this country, but that where he has seen it the 
organisms differ distinctly from the tertian parasite, and their appearance 
coincides exactly with that described by Golgi. For instance, the first stage 
of the quartan organism is similar to that observed in the tertian, except 
that the amoeboid movements are not so active ; as the body develops the 
rods and clumps of pigment are larger and darker than those which appear 
in the tertian form, while the amoeboid movement of the organism is rela- 
tively slight. The full-grown quartan forms are materially smaller than 
those found in the tertian, while the erythrocytes, instead of being expanded 
and decolorized, appear at times shrunken about the body and of a some- 
what deeper old-brass color (Messingfarber). Thayer also states that in the 
quartan form the segmentation of the organism is into from six to ten 
different parts, instead of from twenty to thirty, as is seen in the tertian 
form. 

Although Marchiafava and Celli have described an organism which 
they assert causes a definite form of paludism represented by the paroxysm 
occurring at intervals of twenty-four hours, this has not been corroborated 
by other investigators. We are not justified, therefore, in assuming that 
there is an especial parasite which causes a distinct disease represented by 
the term quotidian. In like manner, we do not at present recognize that 
there is a separate parasite which may cause the symptoms of remittent fever, 
unless it shall be proved to be the sestivo-autumnal. I shall therefore con- 
fine my remarks to the two forms of disease represented by intervals in the 
paroxysms of forty-eight hours and seventy-two hours. 

It is evident from what I have already told you concerning the changes 
which the plasmodium malarise undergoes in the process of its development 
in the erythrocytes that it causes the different symptoms which arise in 
malaria by its action in the different stages of its development. We see 
also that the segmentation of the organism is always coincident with the 



THE BLOOD IN INFANCY AND CHILDHOOD. 



385 



paroxysms, and that the interval between the paroxysms is characterized by 
a distinct and early stage of development of the parasites. 

Koplik has made so especial a study of malaria as it appears in early 
life that I shall quote freely from his writings on this subject. 

In pure types of paludism, either tertian or quartan, one generation of 
the Plasmodium will be found to predominate. In those cases of tertian 
where the paroxysms are found to be of daily occurrence, several genera- 
tions of parasites, each with a different cycle of development, will be 
found in the blood. The same observation will be found to be true where 
irregular types of fever with the tertian parasite are carefully examined, and 
also where the blood in quartan fevers is examined. If more than one gen- 
eration of parasites exists in the blood in a tertian case, the fever may be- 
come quotidian, with daily paroxysms due to the ripening of distinct sets 
of parasites on different days, each set of parasites taking forty-eight hours 
to mature. In like manner, in cases of quartan fever, through the ripening 
of distinct sets of parasites on different days, different combinations occur, 
according to the number of sets of parasites. Thus, while in the form in 
which there is only one parasite the intervals between the paroxysms are 
seventy-two hours, in that in which there are two parasites there may be an 
interval between the paroxysms of only forty-eight hours, and where there 
are three parasites there may be an interval of only twenty-four hours, 
thus representing the quotidian chills described by Mannaberg. This will 
be more clear to you if you examine this table (Table 88), which I have 
arranged for the purpose of definitely explaining the different types of 
paludism as they are now understood by the most recent investigators. 



TABLE 88. 
The Principal Combinations of Paroxysms caused hy the Plasmodium MalaricB. 



Tertian. 

Pure tertian . . . 

(One parasite.) 
Double tertian . . 

(Two parasites. 

Quotidian.) 


Intervals. 


1st day. 


2d day. 


3d day. 


4th day. 


48 hours. 
24 hours. 


Paroxysm. 

Paroxysm. 


No paroxysm. 
Paroxysm. 


Paroxysm. 
Paroxysm. 


No paroxysm. 
Paroxysm. 


QUABTAN. 












Pure quartan . , . 

(One parasite.) 
Double quartan . . 

(Two parasites.) 
Triple quartan . . 

(Three parasites. 

Quotidian.) 


72 hours. 
48 hours. 
24 hours. 


Paroxj^sm. 
Paroxysm. 
Paroxysm. 


No paroxysm. 
Paroxysm. 
Paroxysm. 


No paroxysm. 

No paroxysm. 

Paroxysm. 


Paroxysm. 
Paroxysm. 
Paroxysm. 



The table, as you see, explains how the different intervals in the parox- 
ysms are caused by the development of the parasite on different days. It 
will therefore be easy for you to understand that it is according as the para- 
site happens to develop that Ave have a regular or an irregular ]>eriodicity. 

25 



386 PEDIATRICS. 

Thus, it may happen that we have two parasites, and these two parasites 
may develop on the same day, but at different hours. In this case, sup- 
posing that they are of the tertian type, two paroxysms may occur on 
the same day, followed by an interval of forty-eight hours from the time 
of the full development of each of the parasites until this development 
occurs again. In this way different broods of parasites may cause an 
almost infinite variety of symptoms. Again, we must recognize that it 
is probably true that it is only when the broods of the parasites are espe- 
cially large in number that a pronounced paroxysm is produced, because if 
the brood is small in number and insignificant it may cause only a greater 
or less rise of temperature in place of a pronounced paroxysm. You see 
that in this way we can probably explain those different forms which have 
been designated as remittent fever. That is, on the intervening day, when 
there is no paroxysm, but only a continuous heightening of temperature, it 
may be that the broods have developed only sufficiently to produce fever and 
not a paroxysm, and we shall probably in the future, by a more extended 
study of this parasite in all its phases and under all circumstances, be able 
to show that it is a variation in numbers as well as in the kind of the parasite 
which causes these distinct differences in the symptoms of malaria. 

It has been noticed that the administration of quinine tends to interfere 
with the regularity of the time of the paroxysm, and in this way other 
variations may occur. It has also been noticed that if the paroxysm comes 
earlier in the day than it has been doing, the disease is apt to be of a severe 
type and to be growing worse, while if the interval is lengthened and the 
attack is found to come at a later hour in the day than usual, it is a sign 
that the disease is amenable to treatment, is of a benign character, and is 
tending towards recovery. 

The tertian form is the one which is by far the most common in this 
country, and the one which is most influenced by the administration of qui- 
nine, the other form, represented by the quartan, being peculiarly difficult 
to manage with quinine. In young infants the tertian form in its quotidian 
variety is met with most commonly. In older children, in my experience, 
it is the pure tertian that is most common. It will be noticed, by glancing 
at the table (Table 88, page 385), that the quartan form of paludism can 
never represent by its intervals and paroxysms the pure tertian form. 

Pathology. — There are no especial differences between the pathological 
lesions found in the malaria of children and those which occur in adults. 
I shall, therefore, not dwell on this part of the subject, but shall merely 
state what Thayer has said concerning this disease. 

In acute cases of malarial fever, on examination with the microscope, 
the cerebral capillaries are found to be crowded with malarial parasites. 
There is usually a marked granular degeneration of the endothelium of the 
vessels. 

The spleen is always enlarged. The capsule is tense. The parenchyma 
is cyanotic, of a slaty-gray color, and almost diffluent. The pulp of the 



THE BLOOD IN INFANCY AND CHILDHOOD. 387 

spleen is found to contain enormous numbers of red blood-corpuscles, many 
of which contain parasites. It also contains numerous large white elements 
rich in protoplasm, with usually a single bladder-like nucleus and at times 
coarse granulations. These elements are commonly laden with pigment, 
which at times has the same arrangement as it has in the body of the para- 
site itself. There may be free pigmentation in the intercellular spaces of 
the pulp. The small mononuclear elements and the lymphocytes of the 
follicles never contain pigment. The capillaries are usually filled with 
the Plasmodia, while the splenic veins show relatively few, though they 
always contain large cells enclosing pigment or the remains of red blood- 
corpuscles. 

The liver has usually a slaty-gray color. The capillaries are filled with 
leucocytes, which contain numerous pigmented bodies. Relatively few 
Plasmodia are found in the blood-corpuscles in the vessels. 

The lungs show in their capillaries numerous cells containing pigment 
clumps and well-preserved parasites, although it is unusual to find pigment 
in the endothelial cells, in the capillaries, and in the smaller veins. 

In the areas of broncho-pneumonia which may occur, polynuclear leuco- 
cytes are often found, while the large pigmented cells take no part apparently 
in the active inflammatory process. 

The vessels of the kidneys contain relatively few organisms. The glo- 
meruli may be considerably pigmented. There may be marked degeneration 
of the epithelium of the capsule, and at times changes in the parenchyma, 
especially areas of necrosis of the epithelium of the convoluted tubules. 
The other viscera show no special characteristic changes, except, at times, 
that of melanosis. 

In the more chronic form of malaria the ancemia is usually particularly 
marked. The sjjleen is always enlarged and very firm. There is marked 
thickening of the capsule, which is often adherent to the neighboring 
tissue. On section the spleen is generally of a dark brownish-gray color, 
the fibrous tissue throughout the organ being greatly thickened. The liver 
is considerably enlarged, and usually has a grayish-brown or slaty color. 
At times there is a considerable increase in the connective tissue. The 
kidneys show no particularly characteristic changes, though there may 
be considerable pigmentation. The pigment is most marked about the 
blood-vessels and the Malpighian bodies, and sometimes in the region 
of the convoluted tubules. 

There are no characteristic changes in the other organs, except the shity- 
grayish pigmentation. 

Diagnosis. — Malaria as it occurs in early life is far more difficuU to 
diagnosticate by its symptoms than where the disease runs the typical course 
usually seen in the adult. It is the most protean disease which we are callcii 
upon to deal with in young children, and it simulates so closely almost every 
other disease we are likely to meet with that we should always bo on our 
guard, and allow the possibility of the existence of the plasmodiuni makirite 



388 PEDIATRICS. 

in making a diagnosis in a doubtful case where a periodicity is noticed in 
the symptoms. 

The only rational method of determining that we are dealing with a case 
of malaria is the examination of the blood, which at once settles the question 
if the Plasmodium be found. 

Symptoms. — The symptoms of malaria as it occurs in infants and in 
young children are much more varied and far more uncertain than those 
which we are accustomed to meet with in adults. 

The younger the individual the more likely are the pronounced chills 
to be replaced by some other symptom, such as vomiting, delirium, and con- 
vulsions. The paroxysms come more frequently in children than in adults, 
and in young children a condition of apathy and somnolence, sometimes with 
fever, and sometimes accompanied by coldness of the extremities and a col- 
lapsed condition, very commonly replaces the chill of the adult. These 
symptoms, representing the onset of the disease, may often disappear as the 
disease becomes established, and in their place we may meet with the symp- 
toms of some other disease, such as bronchitis, torticollis, and many other 
affections. The symptoms of these other diseases will often continue and 
be very intractable until quinine is given, when they will disappear, and 
thus we shall be led to believe that we have been dealing with one of the 
masked and misleading manifestations of the plasmodium malariae. (Yide 
Case 269, page 610.) 

My experience wdtli malaria in young children is so similar to that of 
Dr. Holt, of New York, who has written more fully on the symptoms of 
malaria in early life than any one else of whom I know, that I shall quote 
from his writings on this subject. 

The susceptibility of the nervous and respiratory systems in young 
children to produce variations in the form and type of malaria is most mis- 
leading in regard to diagnosis, the symptoms referable to a particular organ 
often completely overshadowing the real disease, malaria, and producing an 
entirely new clinical picture. The symptoms often are so indefinite and the 
disease frequently comes on so insidiously that the physician does not see 
the case until it has made considerable progress and the diagnosis thus is 
much obscured. 

In addition to the other symptoms of which I have already spoken, 
severe pain in the head and sometimes in the epigastric region is met with. 
In the form in which the invasion is gradual, the prominent symptoms are 
anaemia, loss of appetite, and frontal headache of moderate type. The 
spleen in the majority of cases is found to be enlarged, but the well-known 
difficulty of detecting an enlarged spleen in young children makes it pos- 
sible that in many cases there is enlargement of the spleen without our 
being able to detect such enlargement by percussion or palpation. 

The time and character of the onset of the disease and of its paroxysms 
are very irregular, so much so, indeed, that it would not be practicable to 
dwell upon the exact differences which occur from those in the adult. 



THE BLOOD IN INFANCY AND CHILDHOOD. 389 

Splenic and hepatic tenderness, and pains in the back, extremities, and 
neck, are occasionally observed, and general cutaneous hypersesthesia is at 
times noticed. As the capsule of the spleen is less resistant in young chil- 
dren than in adults, the organ seems to enlarge more rapidly, and also to 
subside more quickly, in children than in adults. 

The condition of the intestinal tract varies as miioh as do the other 
symptoms. Sometimes constipation is present, and sometimes diarrhcea, 
the latter being the more prominent the younger the child. 

Dr. Holt's observations on the pulmonary symptoms occurring during 
attacks of malaria are so interestmg and important that they should be 
recorded. Bronchitis was found to be the most frequent of all the compli- 
cations occurring in the course of malaria, and again and again proved to 
be intractable until its malarial origin was discovered. Certain acute cases 
appeared to be pulmonary congestions analogous in their pathology to the 
congestions of the spleen and the liver. The pulmonary symptoms in these 
cases were quite uniform and characteristic. The invasion was acute and 
the temperature high, ranging from 40° C. to 41.1° C. (104° to 106° F.). 
The respirations w^ere very rapid, in three or fom- cases reaching 100 in a 
minute, and resembling the superficial breathing of lobar rather than the 
labored breathing of lobular pneumonia. The face was often cyanotic, and 
the pulse varied from 160 to 200 per minute. In one or two cases there 
was marked drowsiness. The physical signs were usually a slight increase 
of vocal fremitus and slight dulness on percussion. The respirations were 
always high-pitched and sometimes broncho- vesicular. Vocal resonance 
was exaggerated, and there were sonorous rales and occasionally coarse and 
fine mucous rales. These signs were sometimes general in both lungs, but 
were usually most marked behind and towards the apices. They were at 
times found to be confined to a single lung and once to a single lobe. When 
first seen they were diagnosticated as cases of pneumonia, but then' subse- 
quent progress and termination convinced Dr. Holt that they were tempo- 
rary manifestations of malaria, for patients who were seen in the afternoon 
with these symptoms would be found the following morning running about 
the house with a normal pulse and respiration, and with only the signs 
of an insio-nificant bronchial catarrh in the chest. These attacks would 

o 

recur on the following days until quinine was administered. Marked 
splenic enlargement was detected in these cases. 

Pneumonia, both lobar and lobular, was occasionally found as a compli- 
cation of malaria. 

Spasmodic asthma of malarial origin was seen in some cases. These 
attacks were accompanied frequently by marked splenic enlargement, and 
were promptly relieved by antiperiodics. 

Prognosis. — The prognosis of malaria in children is good, provided 
that the child is removed from the malarial district and is treattxl ^vith 
quinine. Relapses occm-, even after long intervals of apparent immunity, 
and the disease can recm' a number of times. 



390 PEDIATRICS. 

When a child has been once attacked by the plasmodium malarise, it 
seems to be peculiarly vulnerable to a second attack of the organism. 

Treatment. — Quinine is the only drug which can be relied upon to 
eradicate the plasmodium malarise from the blood, and is the only medicine 
for this purpose which I shall mention. 

It may be given to an infant under six months in doses of 0.03 gramme 
(J grain) ; at one year the dose may be 0.06 gramme (1 grain), at two years 
it may be 0.12 gramme (2 grains), and it can be increased up to 0.3 or 0.36 
gramme (5 to 6 grains) at five and six years. There is little danger of giving 
too large doses of quinine to children, as they tolerate the drug very well. 

The manner of administering quinine is rendered somewhat difficult on 
account of the bitter taste of the drug and its insolubility in water. In 
very young infants, and in fact in the first six or eight months of life, it- is 
well to try the effect of suppositories. In older infants and in children it 
can usually be successfully concealed in a small amount of chocolate cream. 

The time for the administration of the quinine does not have to be regu- 
lated so carefully as in the adult. The dose can often be given with effect 
three or four times in the twenty-four hours. It is commonly given im- 
mediately after a paroxysm. I have been in the habit of giving it about 
eight or ten hours before the paroxysm is expected. It is well to con- 
tinue the treatment with quinine for some weeks after the paroxysms have 
ceased, as the symptoms often return if the quinine is omitted at once. 

The anaemia which always accompanies the disease to a pronounced 
degree should be treated with doses of arsenite of potash, or with some 
mild form of iron, such as the saccharated carbonate or the tartrate of iron 
and potash. 

These prescriptions, varied to suit the individual, are what I am in the 
habit of using in cases of malaria ; 

Prescription 42. 

For an Infant under Six Months. 

Metric. Apothecary. 

Gramma. 

R Quinise sulphatis 

Olei tlieobromse 11 



36 R Quinige sulphatis gr, vi 

25 Olei theobromse giii. 



M. M. 

Ft. suppos. no. 12. Ft. suppos. no. 12. 

S. — One suppository to be used every 6 hours. 

Prescription 43. 

Metric. Apothecary. 

Gramma. 
R Ferri carbonatis saccharati .... 90 R Ferri carbonatis saccharati . . gr. 
Ft. pulv. no. 15. Ft. pulv. no. 15. 

S. — For an infant under 6 months, 1 powder every 8 hours. 

For an infant from 6 to 12 months, 1 powder every 6 hours. 
For an infant from 12 to 18 months, 1 powder every 4 hours. 
For a child of 3 years, 3 powders every 8 hours. 
For a child of 6 years, 3 powders every 6 hours. 
For a child of 12 years, 3 powders every 4 hours. 



THE BLOOD IN INFANCY AND CHILDHOOD. 391 



Prescription 44. 

Metric. Apothecary. 

Gram ma. 



R Ferri et potassii tartratis .... 3 

Glycerini 18 

Aq. destil ad 90 



00 R Terri et potassii tartratis .... ^iiss- 

75 Glycerini ^v ; 

00 Aq. destil ad ^iii. 



M. M. 

S. — For a child 2 years old, 2 c.c, or J drachm, once in 8 hours. 
For a child 4 years old, 4 c.c, or 1 drachm, once in 8 hours. 
For a child 8 years old, 4 c.c, or 1 drachm, once in 6 hours. 
For a child 12 years old, 8 c.c, or 2 drachms, once in 8 hours. 

Prescription 45. 

For a Child Two Years old. 

Metric. Apothecary. 

Gramma. 

R Liq. potassii arsenitis | 96 R Liq. potassii arsenitis Tt\,xvi ; 

Aq. destil ad 120 | 00 Aq. destil ad ^iv. 

M. M. 

S. — 4 c.c, or 1 drachm, to be given every 8 hours. 

In my experience^ malaria may occur at any age. 

Dr. Dane has recently mentioned to me a case (Case 150) of probable 
malaria (the blood was not examined) in an infant a few days old. 

The infant's mother had malaria during her pregnancy, and some of the manifestations 
of the disease appeared ten days before the birth of the infant. The infant from the earliest 
days of its life showed symptoms of severe digestive disturbance, characterized by vomit- 
ing and diarrhoea, and far beyond what could be accounted for by the lack of equilibrium 
of the function of the mother's mammary gland. 

Dr. Dane made a careful physical examination, but failed to detect anything abnormal 
in its thorax or abdomen. 

Observations of the temperature in this case, taken both in the axilla and in the rec- 
tum, showed that it was of an irregular type, varying from 37.2° C. to 38.3° C. (99° F. to 
101° F.) rectal, and that at times in the latter part of the day it rose to 39.4° C. to 40° C. 
(108° F. to 104° F.) axillary. 

Every day at about 1 a.m. there was a paroxysm, represented by cyanosis, coldness of 
the entire skin, both of the body and of the extremities, collapse, and somnolence. These 
attacks, beginning at the seventh day of life, lasted until the twelfth day, when quinine in 
0.03 gramme (J grain) doses, given in suppositories and administered every two hours for 
seven doses, at once and completely checked the paroxysms. 

From this time the attacks entirely disappeared, the food was well digested, and the 
infant seemed perfectly well. 

I have here in the wards to-day two cases (Cases 151 and 152) of 
malaria to show you. 

One is this boy (Case 151), nine years old, who was admitted to my service on the 
13th day of February. 

He lived in a malarial district until one year ago. He had a slight cough, anorexia, 
malaise, night-sweats, and rapid loss of flesh for several weeks. The movements of the 
bowels were rather irregular. According to his mother's report, he had never before 
had any symptoms of malaria. On examining the child you will see that he is pale and 
emaciated. On physical examination you will find that there is resonance over both 
lungs, and on auscultation you will hear a few moist rales and an occasional sibilant 



392 



PEDIATRICS. 



rale. The area of cardiac dulness and the sounds of the heart are normal. The liver is 
not enlarged, but the spleen, as you see, is very much increased in size, and I have marked 
the limits of its enlargement in black. You see that the upper border rises as high as 
the sixth rib in the axillary line, and extends down into the left inguinal region. An 
examination of the urine shows it to be normal. 

Case 151. 




'% 




Boy, 9 years old. Enlarged spleen. Plasmodium malarise found in blood. 

This is a case which represents the tertian form of malaria. The child had never 
had a chill until 3 p.m. two days after entering the hospital. The chill lasted about one 
hour, and was followed by sweating. A paroxysm of some kind, represented either by a 
chill or by a decided rise in temperature with chilly sensations, occurred on the 17th, 19th, 
21st, 23d, 25th, 27th, and 29th of February, March 2, and March 4, and on March 6 there 
was a decided rigor at 4 p.m. On March 8 the paroxysm occurred in the morning at half- 
past twelve. On the morning of March 10 the paroxysm occurred at about half-past 
eleven, and was followed by marked sweating. Between the paroxysms the boy has ap- 
peared to be very well. He has had a fair appetite, and has gradually gained in weight 
and strength. 

On March 10, immediately after the paroxysm, the blood was examined by Dr. "Went- 
worth, and the plasmodium malarise was found. A specimen of the blood, which Dr. 
Wentworth has prepared to show you, is under this microscope (Plate V., p. 330). 
You will see the clusters of pigment in the erythrocytes in the various stages of the devel- 
opment of the parasites. 

Here is the result of the examination of the blood : 



BLOOD EXAMINATION 35. (Wentworth.) 

Erythrocytes 2,935,000 

Haemoglobin 36 per cent. 

Leucocytes 25,500 

Small mononuclear . , 17 per cent. 

Large " 27 " 

Polynuclear 56 " 

Eosinophiles 



THE BLOOD IN INFANCY AND CHILDHOOD. 



393 



A large number of the erythrocytes contained the plasmodium malariae. 

The large number of leucocytes pointed towards some complication, but none was at 
any time discovered. 

The chills continued on March 12, 14, and 16. On March 17 0.36 gramme (6 grains) 
of quinine were given six hours before the paroxysm was expected to return. On March 
18 there was no paroxysm. The quinine was given regularly three or four times a day for 
several days, and the paroxysms have not returned. 

Here is the chart (Chart 6) representing the temperature and pulse of this case. The 
days representing the disease are necessarily only approximate for the first twenty-two 
days, and he is supposed to have entered the hospital on the twenty-third day of the dis- 
ease. The first chill occurred on the twenty-fifth day, as is shown in the chart. 

CHAET 6. 





Days or Disease^ 




F 

107° 
IC6° 
105° 
104° 
103° 
TD2° 
101° 
100° 

i^ 

W' 

97° 

96° 
95° 
150 
140 
130 
120 

no 

100 
'90 
80 
70 
60 
50 
45 
40 
35 
30 
25 
20 
.».5_ 


23 


24 


25 


26|27 


23 2 


,|30 


31 


32 


« 


34 


35 


- 


37 


38 3 


9 40 


4,|42 


■^ 


\f 

4I6S 

4-1.13 

40.5! 

'tOCJ' 

39.4< 

38.8^ 

38.3' 

37.7« 

37.2' 
37 0* 

36 6° 

36.1° 
35 5° 


M L 


... 


M t 


MK 


Si f. 


M Y. M 


E y-i 


-ME 


ME 


ME 


M-E- 


ME 


^TT 


--M E 


m-Tm 


f M V. 


MF. 


M-E 


M-F 






c 








A 




















































c 










































































11 






c 






















c 




c 




c 


' 






\ 


J 










J 


l/| 








1 
















\ 






















1 














t 














1 




, 










y 


\ 


A 


\ 




1/ 


,/ 


7 


s:^-- 


... 


k 


<A 


.1^-. 


V 




w 




11-- 


-- 


^■\ 


-V- 




V- 


V. 


/ 










\ 










V 








■ V 


















































1 








































































1 




























































































1 










\ 


\ 


















\ 








/: 








A ' 




A 


t\ 








R 


/\ 






I\ 


/ 










V 


\ 


/\ 










/ 


" \ 




1 


f 






^ 




i 




V 












\ 




^ 


/ 


\/ 


I 






'»-> 
























1/ 






^J 
























L_ 


_J 




































n 


■~ 




~ 










q 




















i 

1 
.1 


























1 




























































P-IT 


T^fpd / 


^n 


^77 


13 


ro 


^^4 


































































































































= 


L 




J 










= 


= 




— 


= 






= 


u 




i 



Tertian form of malaria. (C means chill.) 



(The subsequent history of this case was that the quinine was omitted, the chills did 
not return, the spleen recovered its normal size, the anaemia disappearod. and the child 
grew fat, and left the hospital in good condition.) 



Here is the second case (Case 152) of malaria to which I have referred. 

A girl, nine years old, who entered the hospital also on the 13th of the month. 

She represents, in contradistinction to the tertian form of malaria seen in the b<\v, a 
case of the double tertian (quotidian) form. She has been living in a malarial district, but 
has never had any previous symptoms of malaria, although a sister living in the same 



394 



PEDIATEICS. 



house has been affected by the disease. Four weeks before entering the hospital she 
had an attack of vomiting, nausea, and headache, without any apparent cause for them. 
These symptoms occurred at intervals for two weeks, when she began to have chills occur- 
ring every day at about 5 p.m. These chills continued, with the exception of four days, 
until her entrance to the hospital. 

On examination you see that she is fairly developed and is very anaemic. On physical 
examination moist rales are heard over the bases of the lungs behind. The heart shows no 

Case 152. 




Girl, 9 years old. Enlarged spleen. Plasmodium malariae found in the blood. 



increase in the area of dulness, but there is a soft systolic murmur over the whole praecordia. 
This murmur is most intense over the pulmonic area. The pulmonic second sound is not 
accentuated. The murmur is heard in the jugular veins. An examination of the abdomen 
shows it to be soft and tympanitic. The liver is enlarged, so that it extends 2.5 cm. (1 inch) 
below the border of the ribs. The edge of the spleen is plainly felt, and the percussion 
dulness extends downward to the level of the umbilicus and upward as far as the sixth 
rib. I have designated it, as you see, by a black line. The urine is high-colored and has 
a specific gravity of 1025, but is otherwise normal. 

On the day of entering the hospital (the 13th) the child's temperature was raised, but 
there was no chill. On the following day, the 14th, there was a chill at 4 p.m. On the 
15th there was a marked chill, with a considerable rise of temperature. 

Immediately after the paroxysm an examination of the blood was made by Dr. Went- 
worth, with the following result : 



THE BLOOD IN INFANCY AND CHILDHOOD. 



395 



the 



BLOOD EXAMINATION 36. (Wentworth.) 

Erythrocytes 2,396,250 

Hsemoglobin 30 per cent. 

Leucocytes . . . . - 5,000 

Plasmodium malarise present. 

It was noted that the splenic enlargement was greatest during the chill. 

On the 16th there was a chill, and the temperature rose to 40.6° C. (105.2° F 
maximum attained during the course of' the disease. 

On the 17th and 18th the chills recurred. 

On the 18th 0.36 gramme (6 grains) of sulphate of quinine were given at 12.30 p.m. 

On the 19th there was no rise in the temperature, and no quinine was given. 

On the 20th and 21st there were no chills, hut a slight rise of temperature, and 0.12 
gramme (2 grains) of quinine were given four times daily. 

To-day, the 22d, she has just had a chill, and the temperature is 40.5° C. (105° F.). 

Here is the chart of this case. 

CHART 7. 



Daijs or Disease. 




F 

107° 
106° 
105° 
104° 
103° 
102° 
101° 
100° 

15 

98° 
97° 
96° 
95° 
150 
f40 

l!P 

120 
110 
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(The subsequent history of this case was as follows. 0.6 gramme (10 grains) of quinine 
were given in the course of each twenty-four hours for the next sixteen days, the spleen 
gradually growing smaller. As the temperature was still irregular, the quinine was then 
increased to 0.72 gramme (12 grains). The temperature remained normal for three days, 
and then was again slightly raised and irregular. Two weeks later the quinine was omitted, 



396 



PEDIATRICS. 



and the spleen was found to be normal in size. Ten days later the child left the hospital 
in good condition.) 

I have here to show you the chart (Chart 8) of the temperature and pulse of a boy 
(Case 153) nine and one-half years old, who was under my care with malaria. 

CHAKT 8. 





Days oF Disease 




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Tertian form of malaria. 



He had been well and strong, and had not been living in a malarial district, but had 
spent a few days in the early part of May in a place where malaria had been known to 
occur occasionally. On May 7, after returning to his home, he complained of feeling tired 
and dizzy. On the following day. May 8, he complained of headache and of feeling chilly. 
He had no appetite, and in the evening was found to have a temperature of 38.6° 0. 
(101.5° F.). He had two movements from the bowels on that day. 

On the next day. May 9, his temperature at 7 a.m. was normal. At 8.45 a.m. he 
complained of nausea, of headache, and of feeling chilly. He had no appetite. His tem- 
perature at 1 P.M. was 40.8° C. (105.5° F.), and his pulse 120. He appeared to be very 
nervous and irritable. 

On the following day. May 10, he felt perfectly well and bright, had no headache, a 
good appetite, a temperature of 37.2° C. (99° F.), and a pulse of 80. He continued to feel 
well until 7.80 p.m., when he complained of headache. 

On May 11 his morning temperature was found to be 38.3° C. (101° F.) and his pulse 
80. He had no appetite, was restless and nervous, but slept for two or three hours. His 
temperature at 8 p.m. was 41° C. (105.8° F.) and his pulse was 120. At 10 o'clock, after 
having a sponge bath given to him at a temperature of 35° C. (95° F.), his temperature 
fell to 38.3° C. (101° F.). He slept well during the night, and perspired freely. The spleen 
was found to be somewhat enlarged on this day, and nothing else abnormal was discovered 
on physical examination. 

On the morning of May 12 the temperature was 36.5° C. (97.8° F.) and the pulse was 
60. He felt perfectly well and bright, and had a good appetite. The movements of the 
bowels were rather loose. 

On May 13 the morning temperature was normal and his pulse was 60. He felt well 
and bright until noon, when he had a rigor lasting twenty minutes. After the rigor he was 



THE BLOOD IN INFANCY AND CHILDHOOD. 397 

sleepy and tired, and at 3 p.m. the temperature was 40.5° C. (105° F.) and the pulse 120. 
At 6 P.M. he felt perfectly well again, his appetite returned, his temperature fell to 38.6° C. 
(101.8° ¥.) and his pulse to 100. 

On the following day, May 14, he felt perfectly well, had a good appetite, and at 7 
A.M. had a temperature of 36.1° C. (97° F.). On this day he had 0.06 gramme (1 grain) 
of quinine given to him three times a day. 

On the following day, May 15, the record was that he had passed a quiet night, and 
that he woke early and seemed nervous. 0.3 gramme (5 grains) of quinine were given to 
him at 6 a.m. His temperature at 7 a.m. was 37.1° C. (98.9° F.). At 9 o'clock he began 
to grow sleepy ; at 9.30 his temperature was 38.6° C. (101.6° F.), and at noon it was 41° C. 
(105.5° F.). At 7.30 a.m. his pulse was 82, at 9.30 a.m. 100, and at noon 120. At the 
time that he was having the high temperature his urine was large in amount and pale in 
color. At other times it was normal. 

0.12 gramme (2 grains) of quinine were given on the following day, May 16, when the 
record was that he had passed a quiet night and that he waked at 2 a.m., seeming to be 
exhausted and complaining of feeling weak. His temperature was 35.5° C. (96° F.) and 
his pulse 48 and very weak. Thirty drops of brandy were given to him, and his pulse 
soon rose to 75 and was of a better character. He then slept until 7 a.m. At 7.30 a.m. 
his temperature was 35.8° C. (96.6° F.) and his pulse was 60. He appeared to feel bright 
and well all day, had a good appetite, and for the first time had a normal movement of the 
bowels. The temperature in the evening was 36.6° C. (98° F.) and the pulse was 60. At 
7.30 P.M. he complained of slight pain in the bowels. 

On the following day. May 17, 0.36 gramme (6 grains) of quinine were given at 5.15 
A.M. His temperature remained normal all day, and his pulse varied from 70 to 80. He 
felt a little sleepy at noon, but his skin was natural. The bowels were moved regularly, 
and there were no abnormal symptoms. 

On the following day. May 18, he was given 0.36 gramme (6 grains) of quinine at 5.30 
A.M. He was perfectly well and bright all day, and had more appetite. He was given one 
grain of quinine three times during the day in addition to the 0.36 gramme (6 grains) at 
5.30 A.M. 

On the following day, May 20, he was out of bed and dressed all day, feeling perfectly 
well. 

From this time until the 27th he continued to take 0.3-0.6 gramme (5-10 grains) of 
quinine during twenty-four hours, and he has since been perfectly well, with no recurrence 
of the malarial symptoms. 

(No examination of the blood was made.) 

I have also here to report to you the records of two infants who appar- 
ently were suflPering from the effects of the plasmodium malari^e, although 
no examination of their blood was made. 

The first one (Case 154) was one year and ten months old. This infant had lived in a 
malarial district until within a few weeks of the time when I saw him in Boston. 

The history which was given to me by his mother was that for several weeks he had 
had attacks, represented by a chill or chilly sensations, occurring every day at about noon. 
These attacks had recurred for about a week or ten days before I saw him. In connection 
with the chill and the fever the infant usually became unconscious, and its feet and hands 
were cold and clammy. 

0.06 gramme (1 grain) of quinine was given to the infant on the 29th of April, and on 
the following day none of the usual manifestations occurred at noon, but at about 4.30 p.m. 
he had a chill and a slight rise of temperature, but was not unconscious. 0.03 gramme {k 
grain) of quinine was then given, and on the following day, April 30, 0.06 gramme (1 gniin) 
of quinine at 10.30 a.m. On this day there was a decided chill, and the rectal temperature 
rose to 40.5° C. (105° F.). During the attiick the child breathed rapidly ; its feet, hands, 
and nose became cold, and it was practically unconscious for some minutes until its circu- 
lation was restored by injections of warm water and brandy. 0.03 gramme [h grain) of 



398 PEDIATRICS. 

quinine was then given three times during the twenty-four hours. On the following day 
none of these abnormal symptoms occurred. On the next day 0.03 gramme (J grain) of 
quinine was given in the morning and again at night, and this dose was continued for a 
few days. 

From this time the symptoms of malaria entirely disappeared, the infant grew less and 
less emaciated, became stronger, had a good appetite, and continued to thrive. 

No enlargement of the spleen was detected in this case. 

The next infant (Case 155) was nineteen months old, and was brought from a decidedly 
malarial district. , 

It had previously been well until three weeks before it was brought to be treated for 
the following symptoms. At the time when its bath was given to it, which was between 
11 and 12 in the morning, it had symptoms characterized by drowsiness and cyanosis, and 
it would fall asleep, and after about half an hour would wake up bright and well. These 
attacks, though short in duration, were very alarming and apparently serious, as, although 
the infant did not have any pain or convulsions, it could not be roused while in the attacks, 
and became so blue and cold that it was feared that it might die in one of them. At the 
time of the attacks the rectal temperature varied somewhat, but was usually about 38.3° C. 
(101° F.). 

The treatment of this case was with sulphate of quinine, sometimes given by the 
mouth and sometimes by means of rectal suppositories. After the administration of the 
quinine for four or five days the attacks entirely ceased and did not return. The infant 
from that time continued to thrive. 

This table (Table 89) contains references to most of the important articles 
which up to the present time have been published on the blood. You must 
remember, however, that it is not a general literature of the blood, but only 
that of an early period of development. It is the source from which I have 
drawn most of my information in the endeavor which I am making to eluci- 
date the subject for you, and in this way I acknowledge what I have received 
from other authors. 

TABLE 89. 

1. Alt und Weiss Anaemia Infantilis Pseudo-Leukaemica. Centralblatt 

fiir die Med. Wissenschaft, 1892, Nos. 24 u. 25. 

2. Andreesen Ueber die Ursachen der Schwankungen im Yer- 

haltnisse der rothen Blutkorperchen zum Plasma. 
Dissert. Dorpat, 1888. 

3. Arnheim und Widowitz . . Scarlatina. Morbilli. 

4. Baginsky Archiv fiir Kinderheilk., Bd. xiii., 1891. 

5. Bayer Ueber die Zahlenverhaltnisse der rothen und weissen 

Zellen im Blute von Neugeborenen und Saug- 
lingen. Dissert. Bern, 1881. 

6. BoTKiN Beitrag zur pathologischen Anatomic der Milz bei 

Pneumonia Crouposa. Dissert. St. Petersburg, 
1892. 

7. BoucHUT et Dubrisay .... Gazette Medicale de Paris, 1878. 

8. Cadet Etude physiologique des Elements figures du Sang. 

Dissert. Paris, 1881. 

9. Canon Ueber eosinophile Zellen und Mastzellen im Blute 

Oesunder und Kranker. Deutsche Med . "Wochen- 
schrift, 1892, No. 10. 

10. CoHNSTEiN UND ZuNTZ . . . . Pfliiger's Archiv, Bd. xxxiv., 1884. 

11. Davidoff . Untersuchungen iiber die Beziehungen des Darm- 

Epithels zum lymphoiden Gewebe. Archiv fur 
mikroskopische Anatomic, Bd. xxix., 1887. 



THE BLOOD IN INFANCY AND CHILDHOOD. 399 



TABLE 89.— Continued. 

12. Demme 17. und 18. Bericht des Berner Kinderspitals, 1880 

und 1881. 

13. Demme Zwei Falle von pernicioser Anamie. Jahresber. a. d. 

Berner Kindersp. , No. 28. 

14. Denis Eecherches experimentales sur le Sang, Paris, 1830. 

15. DuPERiE Sur les Variations physiologiques dans I'Etat anato- 

mique du Sang. These de Paris, 1878. 

16. Ehrlich Earbenanalytische Untersuchungen zur Histologic 

und Klinik des Blutes. Berlin, 1891. I. Theil. 

17. EiNHORN Ueber das Yerhalten der Lymphdriisen zu den 

weissen Blutkorperclien. I. D. Berlin, 1884. 

18. Engelsen .' Yirchow's Jabresbericht, 1884. 

19. Escherich Ein Pall von pernicioser Anamie. Wien. Klin. 

Wochenscb., 1892. 

20. Pang Lo Sperimentale, 1880. 

21. PiscHL Der gegenwartige Stand der Lehre von kindlichem 

Blute. Sammelreferat. Prager Med. Wochen- 
schrift, No. 12 u. f., 1892. 

22. PiscHL Zur Histologie des kindlichen Blutes. Zeitschrift 

fiir Heilkunde, 1892. 

23. Flemming Zellsubstanz, Zellkern, Zelltbeilung. 

24. Gabritschewsky Grundriss der norm, und patbolog. Morphologie des 

Blutes, 1891. 

25. GuFFER Eevue Mensuelle, 1876. 

26. GuNDOBiN Ueber die Morphologie und Pathologie des Blutes 

bei Kindern. Jahrb. f. Kinderheilk., Bd. xxxv., 
1898. 

27. Halla . . , Ueber den Hamoglobingehalt des Blutes und die 

quantitativen Verhaltnisse der rothen und weissen 
Blutkorperchen bei acute fieberhafte Krankheiten. 
Zeitschrift f. Heilk., 1893, Bd. iv. 

28. Hammeder Centralblatt fiir Gynakologie, 1879. 

29. Hammerschlag Ueber das Yerhalten des spec. Gewichtes des Blutes 

und Krankheiten. Wien. Klin. Wochensch., 1891, 
und Centralblatt fiir Klin. Med., 1891, No. 44. 

30. Hayem Du Sang et de ses Alterations anatomiques, Paris, 

1889. 

31. Hayem L'Anemie des Nourrissons. Gazette des Hopitaux, 

1889, No. 30. 

32. Hetaguroff Pathologische Anatomie des Blutes bei Unterleibs- 

typhus. Dissert. St. Petersburg, 1891. 

33. Hock und Schlesinger . . . Blutuntersuchungen bei Kindern. Yorljiufige Mit- 

theilungen. Centralblatt fiir Klin. Med., 1891. 

34. Hock und Schlesinger . . . Hiimatologische Studien. Franz Deuticke, Leipzig 

und Wien, 1892. 

35. Yon Jaksch Ueber Leukiimie und Leukocytose im Kindei^- 

alter. 

36. YoN Jaksch Ueber Diagnose und Therapie der Erkrankungen 

des Blutes. Prager Med. Wochensch., 1890, Nos. 
22, 23, 31, 33. 

37. Lloyd Jones Journal of Phj-siology, vol. viii. Part 1, 1887. 

38. KiKODSE Pathologische Anatomie des Blutes bei Pneumonia 

Crouposa. DisseTt. St. Petersburg. 1890. 

39. Klein Centralblatt fiir Med. Wissensch., 1872. 



400 PEDIATRICS. 



TABLE 89.— Continued. 

40. Klein Untersuchungen iiber Formelemente des Blutes und 

ihre Bedeutung fiir die praktische Medicin, 1890, 

41. KOlliker Ueber die Blutkorper eines menschlichen Embryo. 

Zeitscbr. fiir rat. Med., 1846, No. 4. 

42. KoTSCHETKOFF Morphologiscbe Veranderungen des Blutes bei 

Scharlach. Dissert. St. Petersburg, 1891. 

43. KrUger Ueber das Verhalten des fotalen Blutes im Moment 

der Geburt. Dissert. Dorpat, 1886. 

44. Laache Quoted by Eeinert. 

45. Leichtenstern Untersuchungen iiber der Hamoglobingebalt, Leip- 

zig, 1878. 

46. Lepine Comptes-rendus de la Societe de Biologie, 1876. 

47. VoN Limbeck Zeitschrift fiir Heilkunde, 1890. 

48. Von Limbeck Ueber entziindliche Leucocytose. Wiener Med. 

Presse, No. 43, 1889. 

49. VoN Limbeck Grundriss einer Klin. Pathologie des Blutes. Jena, 

1892. 
60. LiTTEN Zur Pathologic des Blutes. Berl. Klin. Wochensch., 

1883 und 1889. 
51. J. Loos Die Anamie bei hereditarer Syphilis. Vorlaufige 

Mittheilung. Wien. Klin. Wochensch., No. 20, 

1892. 
62. J. Loos Ueber das Vorkommen kernhaltiger rdther Blut- 

zellen bei Kindern. Wien. Klin. Wochensch., 

No. 2, 1891. 

53. LuzET Etude sur les Anemies de la premiere Enfance. 

Dissert. Paris, 1891. 

54. Mandybur Vorkommen und diagnostische Bedeutung der oxy- 

philen und basophilen Leucocyten im Sputum. 
Wien. Med. Wochenschrift, Nos. 7 bis 9, 1892. 

55. Maragliano Beitrag zur Pathologie des Blutes. Berliner Klin. 

Wochensch., No. 31, 1892. 

56. Moleschott Wien. Med. Wochensch., 1854, No. 8. 

57. Monti und Berggrun .... Die chronische Anamie im Kindersalter. Leipzig 

(Vogel), 1892. 

58. MtJLLER Klinische Beobachtungen zur Verdauungsleukocy- 

tose. Zeitscbr. fiir Heilk., 1890. 

59. MtJLLER Ueber Mitose an eosinophilen Zellen. Archiv fiir 

Exp. Path, und Pharm. , 1891. 

60. MtJLLER Ueber Leukamie. Deutsches Arch, fiir Klin. Med., 

Bd. xlviii. Heft i. u. ii. 

61. MtJLLER UND EiEDER .... Ueber das Vorkommen und die klinische Bedeutung 

der eosinophilen Zellen im circulirenden Blute des 
Menschen. Deutsches Arch, fiir Klin. Med., Bd. 
xlviii. Heft i. u. ii. 

62. H. MtJLLER Die progressive perniciose Anamie. Zurich, 1877. 

68. MuLLER Blutbildung. Sitzungs-Bericht der Akad. der 

Wiss., 1889. 

64. Nasse . Untersuchungen zur Physiologic und Pathologie 

des Blutes. Wagner's HandwOrterb., Bd. i. S. 
138. 

65. Nauntn Ueber den Hamoglobingebalt des Blutes bei den 

verschiedenen Krankheiten. Corresp.-Blatt fiir 
Schweizer Aerzte, 1872, No. 14. 



THE BLOOD IN INFANCY AND CHILDHOOD. 401 



TABLE ^'d.— Continued. 

66. Neumann Centralblatt fiir Med. "Wissensch., 1869, und Archiv 

d. Heilk., Bd. x. 

67. Neusser Klinisclie hamatologische Mittheilungen. Wien. 

Klin. Wochensch., Nos. 3 und 4, 1892. 

68. Otto Inaug. Dissert. Halle a. S., 1893. 

69. Panum Die Blutmenge neugeborener Hunde und das Ver- 

halten ihrer Blutbestandtheile verglichen niit 
denen der Mutter und alterer Geschwister. 
Vircbow's Arcbiv, Bd. xxix. 

70. Parrot L'Atbrepsie. Paris, 1877. 

71. K. Pick Untersucbungen iiber die quantitativen Verbalt- 

nisse der Blutkorpercben bei Yariola. Arcbiv fiir 
Dermat. u. Sypb., Bd. xxv., 1893. 

72. PoPOFF Patbologiscbe Anatomie des Blutes und der blutbe- 

reitenden Organe unter dem Einflusse der Hamo- 
globinurie bervorrufenden Substanzen. Dissert. 
St. Petersburg, 1892. 

73. Preyer Pbysiologie des Embryo, 1886. 

74. Quincke Ueber perniciose Anamie. Volkmann's Samml. 

Klin. Vortrage, No. 100. 

75. Quincke Weitere Beobacbtungen iiber perniciose Anamie. 

Deutscbes Arcb. fiir Klin. Med. , Bd. xx. 

76. Keinbrt Die Zablung der Blutkorpercben. Leipzig (Vogel), 

1891. 

77. Eieder Beitrage zur Kenntniss der Leukocytose. Leipzig 

(Vogel), 1892. 

78. Saenger Archiv fiir Gynakologie, Bd. xxxiii. , 1888. 

79. Sahli Arcbiv fiir Gynakologie, Bd. xxxiii. S. 181. 

80. ScHAEFER Beitrage zur Histologic der menscblicben Organe. 

Sitzungs-Bericbt der Akad. der Wissenscbaften, 
Band c, Wien, 1891. 

81. ScHERENZiss Untersuchungen iiber das fotale Blut. Dissert. 

Dorpat, 1888. 

82. ScHiFF UeberdasquantitativeVerbalten der Blutkorpercben 

und des Hamoglobins bei neugeborenen Kindern, 
etc. Zeitscbrift fiir Heilkunde, Bd. xi., 1890. 

83. ScHMALZ Zur Untersucbung des spec. Gewicbtes des menscb- 

licben Blutes. Deutscbes Arcb. fiir Klin. Med., 
Bd. xlvii. 

84. Ad. Schmidt Demonstration mikroskopischer Praparate zur Patho- 

logic des Asthma. Yerhandl. des XI. Internat. 
Congresses fiir innere Med. 

85. Schuecking Berliner Klin. Wochenscbr. , 1879. 

86. Schwartze Ueber eosinopbile Zellen. /. D. Berlin, 1880. 

87. Senator Berliner Klin. Wochenscbi;., 1882, No. 35. 

88. SiLBERMANN Zur Hamatologic des Neugeborenen. Jabrb. fiir 

Kinderh., Bd. xxvi. Heft ii. 

89. J. SoMMA Ansemia Splenica Infimtilis. Allgenieine AViener 

Med. Zeitung, 1891. 

90. SOrenson Jahresbericht iiber die Fortscbritto der Pbysiologie 

und Anatomie, S. 192-197. 

91. Stierlin Deutscbes Arcbiv fiir Klin. Med., 1889. 

92. Troje Ueber Leucamie und Pseudoleuciimie. Bcrl. Klin. 

Wochenscbr., 1892, No. 12. 
26 



402 PEDIATRICS. 



TABLE S9.— Continued. 

93. TscHiSTOWiTSCH Bolnitschnaja Gazette, Botkin, 1890. 

94. TiJMAS Gazetta, Botkin, 1885. 

95. UsKOFF Blut als Gewebe, 1890. 

96. Weiss Das Yorkommen und die Bedeutung der eosinopliilen 

Zellen und ihre Beziehungen zur Bioblasten- 
theorie Altmanns. Wiener Med. Presse, Nos. 
41-44, 1891. 

97. Weiss Beitrage zur histologisclien und mikrochemischen 

Kenntnisse des Blutes. Wien, 1892, Alfred 
Holder. 

98. Weiss Die Wechselbeziehungen des Blutes zu den Organen, 

etc. Jahrbucb fiir Kinderheilk. , Band xxxv., 
1893. 

99. Welcker Prager Yierteljabrschrift, TV. Jabrgang, 1854. 

100. WiDOWiTZ Hamoglobingebalt gesunder und kranker Kinder. 

Jabrb. fiir Kinderbeilk., 1888. 

101. WiSKEMANN Zeitscbrift fiir Biologie, Bd. xii., 1876. 

102. Woino-Oransky Beitrage zur Morpbologie des Blutes der Neuge- 

borenen. Dissert. St. Petersburg, 1892. 



DIVISION VIII. 

DISEASES OF THE NEW-BORN, 



LECTURE XVIII. 

MATERNAL IMPRESSIONS.— THE HEAD.— THE NECK. 

TJxDER the designation " diseases of the new-born" I shall now describe 
to you a series of cases which occur so early in life that they are most 
conveniently placed in a class by themselves. I shall not attempt to dwell 
upon all the conditions which are met with either at birth or within the 
first few weeks of life. That would requu^e more sjDace and time than the 
scope of these lectures will allow. 

The diseases which we speak of as "diseases of the new-born" are 
distinct from those which are acquired later in life, in that they represent in 
almost every case an arrest of the normal development which should occur 
during intra-uterine life. This I have already referred to in my introduc- 
tory lecture (Lecture I., page 19), and I only wish to impress again upon 
your minds that a stage of development which is normal at a certain period 
of intra-uterine life becomes abnormal if it persists to a later period, and that 
this persistence of an early stage of development constitutes in the great 
majority of cases what is known as congenital malformation. Such a failure 
of development may be the result of intra-uterine inflammation, which, 
eitlier by crippling the various functions or by arresting the normal intra- 
uterine growth, produces a condition of disease at birth. In many cases, 
however, the causes are so obscure as to elude our usual methods of exami- 
nation. " Diseases of the new-born" may also be made to include certain 
abnormal conditions which arise immediately after birth or in the early 
days of life. 

Although many of these affections must pass into the hands of the 
surgeon for treatment, yet it is very important for the medical practitioner 
to be able to recognize at once their true nature and their significance. I 
shall, therefore, in this lecture attempt in a few words to tell you of some 
of the more common surgical affections of the new-born, as well as of 
those that are of a purely medical nature. In speaking of these dis- 
eases I shall, for the purpose of simplicity, classify tliem into diseases of 

408 



404 PEDIATRICS. 

the head and neck, diseases of the trunk, diseases of the extremities, and 
general diseases. 

MATERNAL IMPRESSIONS. — A few words should be said concern- 
ing the subject of maternal impressions. For many years there has been 
accumulating a considerable amount of evidence showing that a violent 
mental impression made upon a woman who is at the time carrying a child 
may be followed by a physical or mental defect in the child which bears 
a striking relation in character to the impression made upon the mother. 
Thus, Sir Walter Scott narrates that King James the First could not 
endure the sight of a drawn sword. This feeling has been attributed by 
those who believe in maternal impressions to the terror which his mother 
experienced at witnessing the murder of Rizzio. Still more numerous 
are the facts adduced to prove that bodily defects, such as harelip, club- 
foot, and hairy mole, may be caused by strong impressions of pain or terror 
experienced by the mother at the time when the foetus is in a certain 
stage of intra-uterine development. Interesting as these instances are, I 
think it is the general belief that nothing more has been proved than that 
they depend on a coincidence. The final decision on this obscure subject 
must rest on future investigation, and may cause us to guard a woman 
during her pregnancy from all unpleasant impressions with far more care 
than we do at present. 

THE HEAD. — The normal average head at birth may be misshapen 

from various causes. Of the conditions 
which may cause unusual appearances, I 
shall refer merely to the most common. 
One of these conditions is called caput suc- 
cedaneum, a case of which I have here to 
show you. 



Case 156. 




Caput succedaneum. Male, 2 hours 



Caput Succedaneum. — This infant (Case 156), 
a male, two hours old, presents a swelling over the 
right parietal bone extending back to the occiput and 
causing an irregular tumor and a great increase in 
the antero-posterior diameter of the head. You will 
notice that the tumor does not fluctuate. 

The presentation was occiput left anterior, and no 
old. ~ instruments were used. You see that the swelling 

corresponds to the place where there was the least 
pressure,— that is, the presenting part. It is needless to say that this caput succedaneum 
requires no treatment, as it gradually disappears of itself by absorption in a few days. It 
is simply a swelling of the scalp caused by a passive congestion with extravasation of blood 
and lymph into the connective tissue external to the pericranium. 

Caput succedaneum must be carefully distinguished from another swell- 
ing of the scalp, cephalhsematoma, which may occur in connection with it, 
and which appears as the caput succedaneum disappears. 

Cephalh.1]MAT0MA. — During labor a hemorrhage may take place 
from the blood-vessels of the head which gives rise to a tumor in one of 



DISEASES OF THE NEW-BORN. 



405 



three situations : (1) between the occipito-frontalis aponeurosis and the peri- 
osteum ; (2) between the periosteum and the skull ; or (3) between the skull 
and the dura mater. The first two are known as external cephalhsematoma, 
the last as internal cephalhaematoma. The cause cannot be entirely pressure 
over the presenting part, as they have been found in breech presentations. 

External Cephalhsematoma. — By far the most common form is that in 
which the tmnor has formed between the skull and the periosteum. It 
shows itself as an irregular circular swelling over a parietal bone, and gives 
on palpation a distinct feeling of fluctuation. The skin over it is not 
discolored or reddened. In those that have existed for a few days a bony 
wall can be felt surrounding the tumor, the edges of which give a crackling 
sensation under the finger. In this stage it may strongly suggest a fluid 
tumor coming through a circular hole in the skull. 



The case (Case 157) which I have here to show you to-day is one of double cephalhse- 
matoma of the external variety ; that is, it is an extravasation of blood under the pericranium. 

Its base, corresponding to the denuded bone, 
is oval or circular. You will notice the bulging Case 15 

tumors on each side of the sagittal suture with a 
deep sulcus between them. On palpation you will 
get fluctuation, and on feeling the circumference of 
the tumor an elevation and crackling sensation as 
though you were touching fine crystals of ice on 
the edge of water which is beginning to freeze. 

Cephalhsematoma is distinguished from 
caput succedaneum by its sharp limitation 
to one of the parietal bones, by its fluctua- 
tion, and, if seen late, by its surrounding 
bony wall. It can be diagnosticated posi- 
tively by the withdrawal of some of the 
fluid by a hypodermic syringe. Another 
condition which may simulate it somewhat 
is a depressed fracture. The differential 
diagnosis from this latter condition can 
best be made by remembering the fact 
that the resistant rim of the cephalhse- 
matoma is raised above the level of the surrounding bone, and is somewhat 
compressible, while on the inside it can be felt to slope evenly towards a 
fluctuating centre. In fracture no such arrangement occurs. 

I shall now call your attention to this preparation (Fig. 86, page 406) 
of a double external cephalhsematoma from the AVarreu Museum. 

You see on the left side of the skull (the right side of the picture) tlie 
integument has been nearly removed, showing a raised bony rim. 

On the right side of the skull (the left side of the picture) the integu- 
ment has been cut off* and partially deflected, showing the cavity n\ hich 
contained the effused blood. 




Double cephalhaematoma. Infant, 
4 days old. 



406 



PEDIATRICS. 

Fig. 86. 




Double external cephalhsematoma. Both parietal bones. Warren Museum, Harvard University. 

Fig. 87. 




External cephalhseniatoma. Parietal bone dissected. Warren Museum, Harvard University. 



DISEASES OF THE NEW-BOJRN. 



407 



The next specimen (Fig. 87) is a parietal bone dissected so as to show the 
condition of the bone in a case of external cephalhsematoma. 

This specimen shows well the raised rim and the porous condition of the 
bone imderlvmg the tumor. In two or three places the bone substance has 
entu^elv disappeared. 

Internal Cephalhsematoma. — Internal cephalhsematoma is situated 
between the inner surface of the skull and the diu-a mater, and is rare. It 
is at times found in connection with the external variety. 

The prognosis m this class of cases is bad. They are usually fatal, and 
there is no kno^m treatment which can save them. I have here to show 
you the preparation (Fig. 88) of a skull taken from a case (Case 158) of 
internal and external cephalhaematoma. 

Fig. 88. 




Internal and external ceptialhsematoma. Warren Museum, Harvard University. 

The specimen was taken from an infant which was born at the Lyiug-in 
Hospital. Its death was caused by a large cerebral hemorrhage resulting 
from the internal cephalhaematoma. It shows only the external cephalhae- 
matoma, which occupies the left parietal and occipital regions (shown on left 
of picture). Corresponding to this external cephalhaematoma was a large 
effusion of blood occupying a space about 2.5 cm. (1 inch) in diameter, 
and lying between the dura mater and the brain substance, ^^•llich was 
compressed by it. 

Mexixgocele. — By the term meningocele is understood a protrusion 
of some part of the membranes of the brain through a hole left in the 
cranial wall bv defective ossification. In some instances this is caused by 



408 PEDIATRICS. 

an intra-uterine hydrocephalus. These tumors generally contain some of 
the cerebro-spinal fluid in the bag of membrane. Such fluid can often be 
reduced into the skull by gentle pressure, but at the risk of bringing on 
symptoms of cerebral disturbance. 

This case (Case 159) shows a small meningocele above the left ear about 2.5 cm. 
(1 inch) in diameter. 

Some fluid was withdrawn from it by an aspirating needle, and the contents of the 
sac proved to be serous without cells. The sac refilled 
Case 159. after tapping. No more extensive operation on it has so 

far been undertaken. 

The history of this case is that the child is rhachitic. 
It had a fall some time ago and struck its head. Noth- 
ing abnormal was noticed about the child previous to the 
fall, but since the accident this swelling appeared above 
and behind the ear. The swelling increases in size 
when the child cries, is soft, fluctuating, and not tender. 
The knee-jerks and sensation are normal. The ophthal- 
g 'W moscopic examination discloses nothing abnormal. 

^^* ' ^m A much more serious condition is shown in the 

^ ■. ■ . ' ... 3 meningocele of this infant (Case 160). 

Meningocele. Female, 3 years j^ ^g ^ ^^^^^ ^^^ ^^g ^^^ ^^e^g ^^^ ^^^^ operated 

upon. Behind its left ear was an irregular tumor about 
7.5 cm. (3 inches) long. The ear was pushed forward, and appeared to be growing from 
the tumor. The labor was normal , and the infant at birth was perfectly healthy and well 
formed, except for the tumor, which was congenital. On examination the tumor was found 
to be fluctuating and translucent. There were large veins on its surface.' Pressure on the 
tumor caused no symptoms. No impulse could be felt on crying, nor did pressure cause 
any cerebral symptoms. On aspirating it, 45 c.c. (IJ ounces) of a clear reddish fluid 
were withdrawn. This fluid contained red blood-corpuscles and a few endothelial cells. 
No unfavorable symptoms followed the aspiration. After the withdrawal of the fluid two 
openings could be felt, the anterior probably connecting with the external auditory meatus 
and the posterior with the anterior fontanelle. The tumor was increasing in size so rapidly 
that an operation was decided upon. On removing it an opening in the skull large enough 
to admit two fingers was found. 

The child made a rapid recovery from the operation, and now has only a scar behind 
the ear. There were no cerebral symptoms. During convalescence and up to the present 
time the child has seemed to be mentally bright. 

Encephalocele.— Still more common than the pure meningocele is 
that condition in which the hernia contains some of the cerebral substance 
as well as the membranes. This condition is called encephalocele ; or if, as 
is often the case, it contains a portion of a dilated ventricle, so that the 
tumor is filled with cerebro-spinal fluid, it is known as hydro-encephalocele 
or as hydro-encephalo-meningocele. 

Here are some photographs of a remarkable case (Case 161) of hydro- 
encephalocele which was treated by Dr. Lovett in the hospital. 

The infant from the time of its birth had tonic and clonic convulsions, occurring 
usually as often as once in three hours. It was brought to the hospital when it was two 
months old. It was well formed in every way, except that it had a tumor on the back of its 
head which was at least one-third as large as its skull. The tumor was only partly covered 
with skin, the upper part of it being a thin translucent membrane. It communicated with 



DISEASES OF THE NEW-BORN. 409 

the brain through a large square hole in the hack of the skull. The tumor fluctuated 
slightly and appeared to be a multilocular cyst, for when it was aspirated only a part of the 
contained fluid could be withdrawn. 

The tumor was removed by Dr. Lovett and the wound sewed up tightly. The cyst 
was found to contain a viscous fluid with slight flakes in it which proved to be particles of 
cerebral substance. 

The convulsions immediately became less frequent, and ultimately on treatment with 
bromide of potash disappeared almost entirely. 

The infant in other respects was very little affected by the operation, and recovered 
rapidly. After remaining in the hospital two weeks it was taken to its home, where it died 
some months later of some intercurrent affection. 

Eegarding these tumors in general, it is enough to say that you should 
view with suspicion any fluctuating swelling that seems to have a deep 
attachment in the neighborhood of one of the cranial sutures. The most 
frequent seat of these tumors is in the occipital region and at the root of 
the nose. Their treatment has not proved very successfiil. Some few may 
steadily decrease of themselves and ossification may block iip the abnormal 
opening. Pressure and the injection of Morton's fluid have both been 
tried, and in some cases have been attended with success. At present the 
operative plan of treatment is considered the best. Without interference 
the tendency is usually towards rupture of the hernia, convulsions, and 
death. 

Anencephalia. — As you have been taught in your course on embry- 
ology, the cerebro-spinal system is formed from the medullary tube, which is 
made by the infolding of epiblast along the medullary groove : if the for- 
mation of the medullary tube is for any reason incomplete, or if the dorsal 
wall of the tube is destroyed, the cerebrum or part of the cerebral axis will 
remain rudimentary. According to the amount of interference with the 
development we may find more or less of the brain remaining in a rudi- 
mentary condition, and thus producing greater or less degrees of what is 
called anencephalia. Total anencephalia is rare. Partial anencephalia is 
much more common. These cases are not of especial interest to us, as it is 
exceptional for them to live beyond a few days. 

Congenital Hydeocephalus. — One of the more common malfor- 
mations of the head is a hydrocephalic condition at birth. It is called 
congenital hydrocephalus, and I shall describe it in a later lecture (Lecture 
XXX., page 634), on diseases of the brain. 

Harelip. — The clearest way in which I can describe to you the malfor- 
mation which I am now to consider is to remind you in a few words of the 
manner in which the parts around the mouth of the embryo are formed. 
You can then see at a glance how a failure of any part of the process iu 
the development of that region will give rise to the several defects known 
as single or double harelip and cleft pahite. At first the fore-gut of the 
embryo does not communicate with the outside, but ends blindly under the 
anterior region of the hind-brain. Over the end of the fore-2:ut curve the 
mid-brain and fore-brain, causing a prominence on the ventral surface of the 



410 PEDIATRICS. 

embryo. As the heart develops, another prominence is formed below the 
end of the fore-gut, and between these two prominences a wide shallow pit 
is found. At the bottom of this pit there is but a single velum, which 
separates the end of the fore-gut and the primitive mouth or stomodseum ; 
later the velum is broken through and the two cavities form one canal. 
Above, this primitive mouth is bounded by the fronto-nasal process. Below, 
the boundary is made by the first visceral or mandibular arch, which has 
grown around the fore-gut from each side and has joined in the middle in 
front. The sides of the upper part of the buccal cavity are made by the 
maxillary processes, which growing from the base of the mandibular arch 
fill up the gap between it and the fronto-nasal process. The sides of the 
mouth are completed by the formation of the cheek-plates. The beginning 
of what in later life is to become the organ of smell is in the form of two 
small depressions, called the olfactory pits, in the sides of the fronto-nasal 
process, and immediately underlying the fore-brain. In the process of 
development these pits deepen and are partially surrounded by a semicircular 
ridge. The thickened inner edge of each olfactory pit now grows down- 
ward into the oral cavity, forming the mesial nasal process, and ends in 
a bulbous enlargement called the globular process. The mesial processes 
then grow backward along the roof of the stomodaeum, forming the nasal 
laminse. The lower portion of the fronto-nasal process, which is originally 
situated between the olfactory pits, and includes the globular processes, gives 
rise to the intermaxillary region, the middle part of the lip and the lower 
part of the nasal septum and the portion of the fronto-nasal process between 
them. The bridge and point of the nose are formed by a pushing out of 
that part of the fronto-nasal process which lies immediately above. So far 
we have been following the development of the internal rims of the olfactory 
pits. The external rims grow also, but less rapidly, and project down- 
ward as the lateral nasal processes. From them are formed the alse of 
the nose. They begin by curling around the lower part of the nasal pits, 
but soon meet and coalesce Avith the maxillary processes of the mandibular 
arch, which you will remember I described to you as growing around each 
side of the roof of the primitive mouth. The lateral nasal processes and 
the maxillary processes eventually join in front with the intermaxillary 
process, and the union of all these makes the upper boundary of the mouth 
and shuts it off from the anterior nares. Behind this anterior bridge the 
nose continues to communicate freely with the mouth. Finally the palatine 
processes grow like two shelves from the inside border of each of the maxil- 
lary processes. These by their union with each other in the middle line and 
with the nasal septum complete the division of the nose and mouth. The 
median union of the palate begins in front by the eighth week and is com- 
pleted by the thirteenth week of intra-uterine life. From what I have said 
you can easily picture how an arrest of this process would result in several 
kinds of deformity. If the maxillary process on one or both sides fails to 
unite with the intermaxillary, a cleft will remain open in the contour of 



DISEASES OF THE NEW-BORN. 411 

the upper lip on one or both sides of the intermaxillary bone, and hence we 
shall have single or double harelip as the case may be. If the cleft extends 
the whole distance from mouth to nostril it is called complete, but if the 
nostril is not reached by the opening it is called partial harelip. If there 
is a failure of the palatine processes to join, one or both nostrils will open 
into the roof of the mouth as well as into the pharynx, aud we shall have the 
malformation known as cleft palate. This may be a huge chasm running 
the whole length of the roof of the mouth, or may be only a small opening, 
or nothing but a bifurcation of the tip of the uvula may be left to show 
that the normal process of development has not gone on to completion. An 
interesting and as yet unpublished observation on the persistence of an early 
condition of development in the lip has been made to me by Professor C. 
S. Minot, of the Harvard Medical School. If you examine the mouths of 
any set of men, you will be struck with the fact that in some of them the 
even contour of the upper lip appears broken by two rounded masses, each 
about the size of a pea, situated side by side nearly in the middle line. 
These are the remains of the two globular processes which have failed to 
be obliterated in the formation of the intermaxillary region. 

Besides their unsightly appearance, which always causes the mother 
great concern, these malformations may so interfere with the infant's 
taking the breast as to render sucking impossible and make it necessary 
to feed the infant with a spoon. 

I have here to show you a typical case (Case 162) of double harelip uncomplicated by 
cleft palate. 

You will notice the large size of the intermaxillary bone, which protrudes considerably 
beyond the margin of the lips and is somewhat twisted upon itself. This alteration of the 
position of the intermaxillary bone may cause the teeth that grow from it to appear in very 
unusual places, as, for instance, protruding from the nostril. 

Case 162. 




Double harelip. 



Dr. J. C. Warren, who has examined the case, will now tell you what 
his ideas are as to the proper time for and the method of operating on 
harelip : 

"The operation for the cure of the deformity of harelip consists in 



412 PEDIATRICS. 

removing the edges of the cleft with the knife or sharp scissors, and in 
bringing the portions of the lip together by sutures. 

'^ The cut may be made so that the lower edge of the wound will project 
slightly, so as to avoid an indentation of the border of the lip when cicatri- 
zation has taken place. This may be accomplished by making a slightly 
curved or V-shaped cut in each margin of the cleft. When there is double 
harelip, the portions of the lip adherent to the intermaxillary bone should 
be refreshed, leaving a V-shaped flap hanging from the septum of the nose. 
The wound when brought together then forms a Y. 

" The sutures which are usually applied produce almost invariably 
unsightly scars, owing to the traction which is exerted when the child cries. 
I have therefore devised a plan • by means of which external scars are 
avoided. This consists in passing a fine wire through the cleft at the 
margin of the alse of the nose and forcing the parts into apposition by a 
perforated shot, which is then clamped to the wire. In the case of single 
harelip the wire passes through the ala of the side affected and the septum. 
One of the shots is therefore concealed in the nostril of the other side. 
My other sutures are of silk, and are so taken that the knots are tied in the 
mouth and the rest of the suture is buried in the deeper portions'of the lip. 
Three such sutures are usually sufficient to hold the lip firmly. A few very 
fine sutures such as are used for intestinal sutures may be applied on the 
exposed surface to make the coaptation of the edges of the wound complete. 
A band of crepe lisse fastened to the cheeks by collodion removes the strain 
sufficiently to enable healing to take place promptly. The wire should 
remain in place for ten days, but the fine sutures should be removed in two 
or three days and the remaining sutures at the end of a week. 

" These operations should be performed during the early weeks of life, 
as the growth of the facial muscles is not then sufficient to interfere with 
the healing of the wound." 

The method of feeding these cases is important. Various devices have 
been used to promote the power of sucking, which is so much interfered with 
by the connection between the nasal and buccal cavities. Rubber nipples of 
peculiar shapes have been used, with the idea of artificially closing the open- 
ing in the hard palate w^hile the infant is being fed. I have always pre- 
ferred, however, to have the infant fed by the spoon, and not to have it suck 
at all until after it has been operated upon and the wound entirely healed. 
In this way we avoid the irritation upon the floor of the nasal cavity which 
would be caused by the introduction of rubber nipples or any other appa- 
ratus. The infants, as a rule, have no trouble whatever in swallowing milk 
introduced into their mouths by means of a spoon. 

The method of feeding premature infants by means of Dr. Breck's tube 
(Fig. 42, page 313) is also a rational way of feeding cases of harelip, pro- 
vided that the infant does not insist on sucking. 

Cleft Palate. — In speaking of harelip I have described most of the 
conditions occurring in cleft palate. The difficulty of feeding, if the cleft 



DISEASES OF THE NEW-BORN. 413 

involves the hard as well as the soft palate, is very great, and must be met 
in the manner just described. The difficulty in articulation and the 
unpleasant sound of the voice are reasons which lead the parents to demand 
early treatment. We should wait a longer time before operating than in 
cases of harelip, as it is seldom wise to operate upon this deformity before 
the child is three years old. 

The operation for cleft of the soft palate is called staphylorrhaphy, and 
is performed in this way. When the child has been put fully under 
the influence of an anaesthetic, and the mouth held wide open with a gag, 
the surgeon seizes the tip of the uvula with his forceps, and by the aid of a 
sharp blunt-pointed history rapidly pares off a thin strip from the tip of the 
uvula to the angle of the cleft. Then, changing his forceps, he takes a 
similar paring from the opposite side, carrying the knife from the top of the 
cleft to the tip of the uvula. The fresh edges are then brought into appo- 
sition by a series of fine wire sutures, which are twisted tight and cut off. 
The levator and tensor palati muscles, together with the palato-pharyngeus, 
are then cut, in order to lessen the tension on the flap. This is accomplished 
by passing a thin-bladed knife completely through the soft palate close to 
the inner side of each hamular process : the han41e is then raised a little 
and the knife withdrawn with its cutting edge downward. The anterior 
wound need be only slightly longer than the width of the blade. 

The operation for closure of a cleft in the hard palate, called uranoplasty, 
is much more difficult, and, owing to the great success which has lately been 
attained by fitting artificial palates, is now passing into disrepute. For 
wide clefts uranoplasty is almost hopeless, but narrow ones may be success- 
fully closed by its aid. It consists in marking out two side flaps parallel to 
the cleft on the roof of the mouth. These are dissected up with as much 
periosteum as possible for a distance a little in excess of the length of the 
cleft. The median edges of these flaps are refreshed and brought together 
by a row of sutures, just as was done in operating upon cleft of the soft 
palate. The final step of dividing the palatal muscles is the same in each. 
By many surgeons the lines of suture are in all these cases protected by a 
rubber plate made to fit neatly into the roof of the mouth. 

The larger the opening in the palate the more successful will be the treat- 
ment by apparatus in comparison with that by the knife, for in the large 
openings there is so little opportunity for refreshing the edges of the open- 
ing and bringing them together that the operation is very apt to be unsuc- 
cessful. In using the apparatus, on the contrary, the larger the opening the 
greater the ease with which the artificial palate can be adapted. The arti- 
ficial palate has also a uvula edge to it, and has in many cases proved 
eminently successful when applied by the hands of an expert. 

Let me here emphasize the fact that after any operation upon the mouth 
of an infant the after-care, and especially the feeding, are of the utmost 
importance. The infant must be watched night and day to see that it does 
not put its fingers to its mouth and thus interfere with the stitches. Of 



414 PEDIATRICS. 

course every time it cries the strain is greatly increased upon the stitches. 
We must, therefore, impress upon the nurse the importance of continually 
amusing the infant. 

ToNGUE-TiE. — In quite a number of cases the frsenum of the tongue is 
abnormally short at birth. In extreme cases the tip of the tongue is so 
closely bound to the lower jaw that it cannot be protruded beyond the line 
of the gum or touched to the roof of the mouth. The mother usually 
notices that the infant does not nurse readily, and brings it to the physician 
to discover the cause. In most cases on passing the finger into its mouth 
the infant is found to suck fairly well ; but there can be no doubt that this 
condition, which is called tongue-tie, interferes somewhat with the process of 
sucking. 

The treatment is to cut the frsenum. This operation should be followed 
by no hemorrhage and requires no dressing. Having the child's head held 
in a fairly good light by an assistant, and guarding the lower part of the 
tongue with the perforated flange of a director, a small cut is made in the 
tense frsenum with a pair of blunt-pointed scissors. By making the cut 
close to the gum there is no danger of wounding the ranine artery. The 
cut is prolonged as far ag is necessary by tearing with the finger-nail. 

Children who have not learned to talk at the usual time in the second 
and third years are frequently brought to me with the statement that they 
are tongue-tied, and the parents wish me to treat this condition. I^arge 
numbers of children are brought to the physician under this supposition, 
but in very few instances are they tongue-tied. These children belong to a 
class which I shall describe when speaking to you of retarded speech (Lec- 
ture XXXVL, page 740). I shall merely say at present that the condition 
is a central one of the brain, and not a local one in the mouth, and that if 
children hear well and are bright and mentally well developed, even though 
they do not speak at the third, fourth, or even fifth year, as a rule they 
learn to speak later. 

Ranula. — Beneath the tongue we sometimes find the mucous membrane 
bulging out as a bluish, translucent tumor which is soft, painless, and semi- 
fluctuating. This condition is called rarmla, and is a retention cyst caused 
by the blocking of a mucous duct. When opened, a small amount of glairy 
fluid escapes, but the collapse of the walls of the cyst brings the edges of 
the cut together and they quickly adhere. The fluid will soon re-collect ; 
therefore the only sure way of dealing with these cysts is to pinch up their 
anterior wall with fine forceps, and with the scissors remove so much of it 
as to leave no opportunity for the edges to adhere. A gentle application 
of nitrate of silver to the edges and interior of the sac after the cut has 
been made with the scissors materially helps to promote the cure. It is 
not common in new-born children, but it occurs often enough to deserve 
mention. 

Ears. — A deformity which is quite frequent at birth, and which increases 
as the infant approaches childhood, is the protrusion of the ears. The ear, 



DISEASES OF THE NEW-BORN. 415 

besides at times being placed in an irregular position on the head, has, in the 
cases to which I am now referring, a tendency to stand out from the head 
farther than is considered normal. This position of the ear usually annoys 
a mother very much, and you will frequently be consulted as to the means 
by which the deformity may be rectified. 

In a large number of cases the persistent application of pressure by 
means of various devices, one of which is a fenestrated cap, will cause the 
ears to be flattened against the side of the head. In intractable cases an 
operation will have to be performed, but it is very simple and does not leave 
an unsightly scar. Dr. Warren's method for operating for this deformity 
is illustrated by one of my cases (Case 16 3), a boy eight years old, in which 
the operation resulted in a marked improvement in his appearance. 

Dr. Warren dissects off a flap from the back of the ear that is shaped 
very much like the wing of a butterfly. A similar flap is taken from the 
side of the head just back of the ear. The two raw surfaces are then 
brought together, and the edges of the wound united with fine sutures. Dr. 
Warren tells me that the amount of tissue removed must be considerably 
larger than would seem at first sight to be necessary, because if the ear is 
not united to the head by a band of considerable thickness the subsequent 
stretching of the cicatrix allows of a return of the deformity. 

Ophthalmia Neonatorum. — This disease has been divided into two 
forms, the catarrhal and the purulent. 

Catarrhal Ophthalmia. — The catarrhal form may be caused by any 
slight irritation of the eyes of the infant. It runs a very mild course, the 
inflammation attacking chiefly the palpebral conjunctiva. Often the only 
symptoms noticed are a slight photophobia and a collection of the secretion 
in the angles of the lids and upon their borders. Its whole course is mild, 
and often it is all over in a few days. 

Purulent Ophthalmia. — Although a considerable number of causes for 
purulent ophthalmia in the new-born have been given, such as trauma, ex- 
posure to light and cold, and others, certainly ninety-five per cent, of all 
cases are caused by infectious material from the genito-urinary tract of the 
mother, and in most instances it is by gonorrhoeal pus. If infection takes 
place during the birth of the child, the symptoms usually begin on the third 
day ; but, as contaminated linen and fingers may carry the infectious material 
to the infant's eyes at a later period, the symptoms may be delayed indefi- 
nitely. The disease begins as a redness of the conjunctiva, with a slight 
discharge from the corner of the eye. This is succeeded with startling 
rapidity by intense inflammation of the lids. In twenty-four hours the upper 
lid may become so much swollen as to overhang the cheek and render opening 
the eye impossible. On separating the lids, a little greenish pus, which may 
even be tinged with blood, wells up between them. At first the cornea is 
unaffected, but if the pus accumulates under the cedematous lids it soon 
shows signs of ulceration. In tlie second twenty-four hours the ulceration 
may perforate the cornea and evacuate the aqueous humor, thus bringing 



416 PEDIATKICS. 

the iris into contact with the posterior surface of the cornea. The inflam- 
mation may extend around the eye and well over the forehead and malar 
prominence, but it does not last in the latter region very long. 

All the symptoms disappear slowly, and recovery takes place, except in 
those cases where from ulceration the cornea has been permanently injured. 

In treating this disease we must be very prompt and energetic. It often 
may be averted by what is known as Crede's method. This consists in 
dropping one or two minims of a two per cent, solution of nitrate of silver 
into each eye of the new-born infant. Although this has been known to 
cause even a considerable amount of irritation, yet it undoubtedly exerts a 
powerful influence in warding oif this dangerous disease. 

After the disease has once begun, two indications must be kept in mind : 
(1) to reduce the inflammation, and (2) to prevent the pus from accumu- 
lating behind the tightly-closed lids. By far the best way of applying 
cold to the eye is by compresses of thin, soft pieces of linen cut into small 
squares. Not more than two thicknesses are to be used at once. These 
compresses are to be cooled by laying them on a piece of ice or floating 
them in ice-water. They must be constantly changed. To remove the 
pus, a gentle irrigation, such as can be easily obtained by using a medicine 
dropper, is sufiicient. 

Remember that this secretion is highly contagious, not only for the 
infant's other eye, but for yourself. Therefore you must avoid all spatter- 
ing, and should cover the infant's well eye before you begin the irrigation. 

You should first turn the child's head a little to the diseased side, and 
with the fingers of the left hand gently separate the lids as far as possible. 
Then, holding the dropper with the right hand, irrigate between the lids, 
directing the stream from the nose. 

This should be done at least every half-hour, day and night, until the 
swelling has so far subsided as to preclude the danger of any secretion being 
retained. 

For irrigation many solutions have been advocated. The most simple, 
and perhaps the best, is a saturated solution of boracic acid, or one of 
bichloride of mercury in the strength of 0.05 gramme (1 grain) to 480 c.c. 
(1 pint) of distilled water. In the later stages of the disease, where all the 
tissues are relaxed, a solution of nitrate of silver, 0.5 gramme (10 grains) 
to 30 c.c. (1 ounce) of distilled water, may cautiously be used once a day. 

It is not within the scope of these lectures to describe in detail scarifica- 
tion of the cornea or other measures which may become necessary to save 
extensive sloughing from strangulation. 

THE NECK. HEMATOMA of the Sterno-Cleido-Mastoid Mus- 
cle. — During the birth of the child, either from the violence of the expul- 
sive efforts of the uterus, or, as more frequently happens, from the pressure 
of the forceps in head presentations, or from too vigorous traction upon the 
feet in breech presentations, or for no assignable reason, the sterno-mastoid 
muscle may be partially ruptured in its sheath and a hsematoma form be- 



DISEASES OF THE NEW-BORN. 417 

tween the torn ends. This tumor may be either in the sternal or in the cla- 
vicular portion of the muscle, or may be just above the junction of the two. 
For a short time it is soft and tender, but gradually it loses its sensitive- 
ness and becomes converted into fibrous tissue, which then tends to contract. 
It may appear as a small tumor, but in infants with fat necks it may not 
be noticeable at first. As turning the head towards the affected side lessens 
the tension upon the swelling, the infant will rigidly hold its head in that 
position. It is in this way that cases of infantile torticollis are thought by 
most writers to arise. 

Treatment. — After the painful stage has passed, the treatment is by 
gentle massage and manipulations addressed to stretching the shortened 
muscle. If these methods fail, the child must be placed in the hands of an 
orthopaedic surgeon for more extended treatment^ either by apparatus or by 
division of the tendinous attachments of the sterno-mastoid muscle. 

Branchial Fistula. — At an early period of development the neck 
of the foetus has along its sides a series of four branchial clefts, which 
communicate freely with the oesophagus and represent the gills of aquatic 
animals. The upper one of these forms the tympanum and the Eustachian 
tube, the rest are normally obliterated. Sometimes we find traces of these 
branchial clefts in the form of small fistulous tracts which admit a probe 
a short distance and end blindly. Their most frequent seat is just above 
the sterno-clavicular articulation, but they may be found anywhere along 
the anterior border of the sterno-mastoid muscle. 

If they do not cause any inconvenience it is better to let them alone, as 
they often prove very intractable to treatment. If they are annoying from 
causing a slight mucous discharge, we can try to eradicate them with the 
galvano-cautery, or by passing a probe into the wound and dissecting from 
around it the lining of the sinus. 

Sometimes the entrance of these fistulse becomes stopped, so that they 
dilate and form large cysts containing mucus, blood, and atheromatous 
detritus. These form at times large and unsightly bunches, which require 
surgical treatment. Often the operation of obliterating them is not an easy 
one, for they are apt to have deep and complicated attachments. 



27 



418 PEDIATRICS. 



IvKCTURK XIX. 

THE TRUNK. 

MASTITIS. — In certain infants during the early days of life we find a 
swelling and hardness of one of the mammae. This condition appears to be 
an inflammatory one, and is abnormal. In connection with the swollen 
condition of the mamma, a secretion is found to come from the nipple which 
corresponds closely to milk, and which has been called " witches' milk.'' 

A number of analyses have been made of this fluid, and here are some 
(Analyses 57 and 58) which represent the composition of it very well. Of 
course only a few drops of the fluid can be expressed from the mamma at 
one time. 

ANALYSIS 57. (Schlossberger.) 

Fat 0.82 

Casein, sugar, and extractives 2.83 

Ash 0.05 

Total solids 3.70 

Water 96.30 

100.00 
ANALYSIS 58. (V. Gesner.) 

Fat . . 1.45 

Casein 0.55 

Proteids 0.49 

Sugar 0.95 

Ash 0.82 

Total solids 4.26 

Water 95.74 

100.00 

This condition occurs in boys as well as in girls, and, as far as I know, 
has no especial significance. With ordinary antiseptic precautions the 
inflammation usually subsides in a few days, leaving the affected breast the 
same size as the other. 

I have here a female infant (Case 164) who represents this condition of 
the mamma. 

She is one week old, and the swelling of the mamma was noticed on the fourth day of 
her life. You see a little fluid looking like diluted milk can be expressed from the mamma. 
The treatment of the case will simply be to keep it thoroughly clean by washing it with 
sterilized water, carefully drying it, and applying a compress with a little simple ointment 
on it. 

DEPRESSED STERNUM.— There are a great many congenital mal- 
formations which may occur in different parts of the thorax. I have here 



DISEASES OF THE XEW-BORX. 



419 



to show you a boy (Case 165) who was born vrith. a depression of the lower 
part of the sternum. 

He is now six years old, and has this rounded depression, about 4 cm. (1^ inches) in 
diameter, beginning at the third costal cartilage and extending to the ensiform cartilage. 
He is perfectly healthy. The cardiac dulness extends to 2.5 cm. (1 inch) to the left of the 
mammary line, and its impulse is in the fourth left interspace. The spinal column is straight. 
The epiphyses of the wrists are slightly enlarged, but there is no other evidence of rhachitis. 
"When he was two months old he had a severe attack of pertussis, which lasted for over two 
months. At five years of age he had a severe attack of bronchitis. 

Case 165. 




Congenital depresiion of sternum. Male. 6 years old. 



You see, therefore, that he has been subjected to influences which would tend to increase 
a malformation of this kind. 

Although this depression of the sternum was present at birth, and has since increased 
in depth and in circumference, it now seems to have ceased to enlarge. The circumference 
of his head and that of his chest measure 50.5 cm. (20 inches). 

The heart seems to be somewhat displaced upward and to the left, but is apparently 
unaffected by its abnormal position, and the boy's circulatory system will probably not be 
injured. 

I have ordered for treatment light gymnastic exercises to broaden the chest and to 
strengthen the thoracic muscles. 

Such a malformation as this sometimes results as one of the changes subsequent to 
Pott's disease. More often the sternum protrudes, but occasionally recession takes place, 
closely resembling the condition in this case. 

PROMINENT STERNUM. — A prominence of the sternum, called 
pigeon-breast, occurs more often than the depression. It may happen 
without an assignable cause, or it may be due to rhachitis, and may also 
result from some spinal distortion, such as that of Pott's disease, or lateral 
curvature. In the latter case the sternum is often tilted to one side. 

SPINA BIFIDA. — I shall next show you a series of that class of 
malformation called spina bifida. Spina bifida consists of a hick of cK^sure 
of the laminae of the vertebra?. This condition is normal at a certain 



420 PEDIATRICS. 

period of intra-uterine life, but when persisting to a later period, and when 
occurring at birth, becomes abnormal from a developmental point of view 
and represents a distinct malformation. As the fusion of the laminae at the 
base of the spinous process takes place in sequence from above downward, 
the most frequent seat for spina bifida is in the lumbar and lumbo-sacral 
regions. There it appears as a tumor situated exactly in the middle line, 
covered sometimes with healthy skin, but as frequently roofed over by 
nothing but a thin adherent transparent membrane. Rarely the tumor is 
solid, containing nothing but an empty sac that has been walled off from 
its connections with the spinal canal. It is then called spina bifida occulta. 
In true spina bifida the tumor is filled with cerebro-spinal fluid, which can 
be seen to increase in amount as the child cries, and can, by pressure upon 
the sac, be forced back, in this case often giving rise to cerebral symptoms. 
According to the contents of the tumor, spina bifida has been divided into 
several varieties. 

1. Spinal Meningocele. — When there is a protrusion of the mem- 
branes filled with fluid the tumor is called a spinal meningocele. 

2. Meningo-Myelocele. — The most common form is where the spinal 
cord, as well as the membranes, is found in the tumor. It then becomes a 
meningo-myelocele. 

The position of the cord in these tumors is a very variable one. It may 
run directly through the tumor, and even be suspended by a kind of mesen- 
tery, or, as is usually the case, it may be spread out like a fan over the 
surface ; in any instance it is rudimentary in character. 

3. Syringo-Myelocele. — Syringo-myelocele is a rare form, in which 
the sac is formed of meninges and cord, the central canal of the cord being 
dilated to make the cavity of the tumor. 

Spina bifida occurs usually in poorly-developed infants, and in a large 
majority of cases it is associated with other malformations, such as congenital 
hydrocephalus, harelip, club-foot, paralysis of the lower extremities, and in 
severe cases there may be incontinence of urine and of faeces. Sometimes 
the infant is well formed and healthy in every other respect. 

If left to itself, the course of spina bifida is in one of two directions : 
(1) spontaneous closure and obliteration of the sac ; (2) ulceration of the 
sac, followed by convulsions and death. In the first case, which is very rare, 
the sac shrivels up and thus eflects a spontaneous cure. I happen to have 
here one of the first class of cases to show you (Case 166). 

This boy, now four and one-half years old, shows an elevated cicatrix in the lumbar 
region, which suggests the former existence of a spina bifida. The case was of such interest 
that it was reported by Dr. Lovett in the Boston Medical and Surgical Journal as a form of 
spontaneous recovery from spina bifida. The case was seen by him when it was eighteen 
months old, and so far as could be learned there had been a large tumor present at birth 
similar to those which I shall presently show you. The sac burst in this case, and, contrary 
to the general result, the child did not die, but was left with paralysis of the legs, which 
makes it stand in this curious and abnormal position. He also suffers from incontinence of 
urine and of fseces. The child has never walked, and it seems probable that the present 



DISEASES OF THE NEW-BORN. 421 

disability is caused by the fact that the nerves were spread on the walls of the sac, as is 
usual in many cases, and that they were incorporated in the cicatrix. 

Case 166. 




Spina bifida. Spontaneous cure. Male, 43^ years old. 

A result like this is, however, very exceptional. The rule is, either that 
there is an ulceration of the sac, followed by a large loss of cerebro-spinal 
fluid, convulsions, and death, or that the opening in the spine being very 
small the loss of fluid is constant, and the result is the same. In some 
instances there is an infection of pyogenic organisms through the walls of 
the sac, which causes a septic meningitis in the cord and finally in the brain. 
Such a case has been reported and beautifully illustrated by Dr. Holt, of 
Xew York, showing the presence of the bacteria and a resulting purulent 
hydrocephalus. 

Here is a picture of another case (Case 167) of spina bifida which will 
illustrate the ordinary course of the aflection. 

It shows a large spina bifida in the dorso-lumbar region. The membrane covering the 
tumor was so translucent that the spinal cord could be plainly seen through it. At birth 



422 



PEDIATRICS. 



there was a small tumor. It filled with fluid at the end of twelve hours, and at the end 
of forty-eight hours it looked as it does in this picture. The top of the tumor suppurated, 
the fluid began to leak away, and the child died within ten days. 

Case 167. 




Spina bifida of dorso-lumbar region. Infant 48 hours old. Died when 10 days old. 

This is the course pursued by the disease in the majority of cases which 
are not operated upon. 

The next case (Case 168) is an illustration of a spina bifida in the lower 

dorsal region. 

Case 168. 




Spina Ijilida in lower dorsal region. Infant 5 days old. Died when 7 days old. 

The sac was not so tense as in the case (Case 167) of which I have just spoken, and 
it was possible by feeling deeply with the fingers to find the opening in the spinal column. 
This opening was about 7.5 cm. (3 inches) long and 3.8 cm. (IJ inches) wide. The tumor 
was not covered with skin, as in the case previously mentioned, but with a thin, translucent 
membrane. 

The infant was seen by Dr. Lovett in consultation twelve hours after birth, and an 
operation was deferred for a few days to see if any favorable change would occur. The 
operation was undertaken on the fifth day, as the sac showed signs of ulcerating and break- 
ing. The sac was excised without apparently injuring the nerves, and the wound was 
closed by a plastic operation. The infant died in convulsions within forty-eight hours of 
the operation. 

The next patient I have to show you (Case 169) is another case of 
spina bifida. 

The boy is now five years old, and has had this large tumor since birth. It is situated 
over the lumbar region of the spinal cord, and is in the median line. The fluid has been 
withdrawn several times for purposes of examination, and when the sac is lax an opening 



DISEASES OF THE NEW-BORN. 



423 



5 cm. (2 inches) long can be felt in the spinal canal. It is elliptical in shape. From the 
fact that the child suffers from incontinence of urine and has a certain degree of paralysis 
of the legs, it is fair to infer that the nerve-supply of the legs and pelvis is incorporated in. 
the tumor. 

Case 169. 




Spina bilida of lumbar region. Male, 5 years old 

This case has been tapped and treated with an injection of Morton's fluid, but this 
treatment was entirely unsuccessful, and although the sac has been aspirated several times 
the fluid has always returned. There is little hope of the boy's being relieved by an opera- 
tion ultimately, and he will probably continue to be a cripple for life. 

Treatment. — Various methods for treating spina bifida have been 
proposed, and some of them warmly advocated. Repeated aspiration is one 
of the most simple, but its results have not been satisfactory. Ligature of 
the neck of the sac, if the sac is small, or the application of a clamp, has 
cured a few cases. Electricity has been recommended for this affection, as 
for about everything else in the field of medicine. 

The two methods that are in the best repute are the injection of Morton's 
fluid and the plastic operation. Morton's fluid is a solution composed as 
is shown in this prescription (Prescription 46) : 

Prescription 46. 

{Morton's Fluid.) 

Metric. Apothecary. 
Gramma. 

R lodi 1 60 R lodi gr. x ; 

Potassii iodidi 1 80 Potassii iodidi gr. xxx ; 

Glycerini 30 ' 00 Glycerin! 51- 

M. M.' 

From 1 to 4 c.c. (15 minims to 1 drachm) are used at each injec- 
tion, which may be repeated several times at intervals of a fortnight. The 
reports of the Clinical Society of England show that more cures and fewer 



424 



PEDIATRICS. 



deaths have been reported following the use of this solution than from any 
other method. 

Another method is the plastic operation. This is performed as follows. 
The tumor is opened, the nerves are dissected carefully from the walls of 
the sac and are returned to the spinal canal : the sac is then sewed up, and, 
if possible, used as a plug for the opening. It has been recommended that 
the laminae of the vertebrae on both sides of the cleft should be broken and 
turned in. Finally, after the excision of all the thin covering, the fresh 
edges of the sound skin are united. To accomplish the closure of the 
wound, and yet to avoid dangerous tension on the stitches, it may, in the 
case of large tumors, be necessary to dissect up two lateral flaps of skin 
from the loins and slide them inward to join in the median line. The 
majority of cases which have been so operated upon have died within a 
week, but the few successes that have been attained lead us to hope that 
with a more perfect technique the results of the operative treatment of 
spina bifida may be such as to warrant our advising it in any case where the 
tumor threatens to rupture and where the child is otherwise fairly developed. 
You must clearly understand, however, that the operation will in most cases 
not help the paralysis or incontinence, and may very possibly increase instead 
of diminish a hydrocephalus, if this latter condition exists as a complication. 




Hydrocephalus, dorsal spina bifida, club-foot. 



This photograph illustrates the condition of hydrocephalus accompanying 
spina bifida, which I have just described. The infant (Case 170), a case of 
Dr. Osier's, represents a combination of spina bifida, hydrocephalus, and 
paralytic deformity of the lower extremities. 



DISEASES OF THE NEW-BOKN. 425 

PHLEBITIS AND ARTERITIS UMBILICALIS.— The cause of 
both of these conditions is a septic infection of the umbilical stump. It is 
considered by most pathologists to begin as an inflammation of the peri- 
vascular cellular tissue^ and only secondarily to invade the walls of the 
vessels. The region around the umbilicus is red and hot, and we may be 
able by gentle pressure to squeeze a few drops of pus from the stump of 
the cord. It is a very dangerous affection, as septic emboli readily pass 
from the infected vessels into the general circulation and set up metastatic 
inflammation in the thoracic as well as in the abdominal organs. 

Treatment. — The treatment is to sustain the infant's vitality by stimu- 
lation and thoroughly to disinfect the umbilicus with solutions of bichloride 
of mercury or carbolic acid, followed by the application of boracic acid or 
iodoform powder. A flaxseed poultice is often of service, and some authors 
recommend placing the infant upon its abdomen in order that gravity may 
aid in draining away the pus. 

CONGENITAL UMBILICAL HERNIA INTO THE CORD.— Dr. 
Howard Marsh, in the Report of St. Bartholomew's Hospital for 1874, 
calls attention to the " familiar anatomical fact that from about the sixth to 
the twelfth week of intra-uterine life the caecum and neighboring portions 
of the ileum are contained in the part of the umbilical cord which is next 
to the body of the embryo, and that they should subsequently withdraw 
into the cavity of the abdomen. In some cases, however, this recession fails 
to take place, and the intestine remains, even up to the time of birth, still 
lodged in the beginning of the cord, which is dilated in the form of a 
membranous sac." Not only may portions of the intestine be thus left 
outside of the abdominal wall, but, as in a case recently operated upon by 
Dr. Warren, the liver may be found lying in a hernial sac made from the 
dilated base of the umbilical cord. 

The infant (Case 171) was sent to Dr. "Warren at the Massachusetts General Hospital 
a few hours after its birth. At the umbilicus was seen the cord, which was greath' dis- 
tended at its point of insertion into the abdomen, forming a tumor 6.5 cm. (2| inches) in 
diameter. The coverings of the cord were inserted into a raised rim of skin, and were 
opaque, so that the contents of the hernia could not be determined. 

When the infant was one day old. Dr. W^arren enlarged the umbilical ring somewhat, 
separated the liver from the myxomatous tissue of the cord, which was in some places 
firmly adherent to it, and returned the mass within the abdomen. The wound was tightly 
closed with strong silk sutures. There was considerable shock following the operation, 
but there were no symptoms of peritonitis. In two weeks the wound had healed, and the 
infant recovered. 

FUNGUS OP THE UMBILICUS.— The umbilical cord, after being 
ligatured at birth, falls off by the seventh or eighth day, leaving a clean, 
dry cicatrix. After the separation of the cord we sometimes -find a red pro- 
trusion, with a moist surface, that may even have a short central canal. This 
is generally due to an imperfect disintegration of the cord. It may bleed 
very readily if touched, and may give rise to a discharge so irritating that 



426 



PEDIATRICS. 



the skin for some distance around the umbilicus becomes eczematous. This 
condition is called fungus or polypus of the umbilicus. 

The treatment is very simple. The larger ones are best removed by 
ligation ; the smaller ones can be destroyed by the application of nitrate of 
silver or the actual cautery. 

MECKEL'S DIVERTICULUM.— A condition which may at first 
simulate umbilical polypus, and of which umbilical polypus may be a 
symptom, is the persistence of a MeckeVs diverticulum. This consists 
in the persistence of a piece of intestine, usually patent, connecting the 
small intestine with the umbilicus. It represents a vitelline duct that failed 
to atrophy when the placental circulation became established, and betrays 
its presence by an escape of faeces from the umbilicus. It is a rare mal- 
formation, but one which you should recognize at once. 

I have here to show you the picture of a case (Case 172) that came to the Infants' 
Hospital last winter during the service of Dr. Lovett. 

Case 172. 




Persistence of Meckel's diverticulum. Infant 3 days old. 

The infant at entrance was three days old and was very well nourished. You will 
notice the protrusion at the umbilicus, on the top of which is a bright red granulating surface, 
appearing black in the picture. There was a considerable fascal discharge from the polypus, 
and the skin of the abdomen was much irritated in its vicinity. A medium-sized probe 
could with ease be passed 6.5 cm. (2^ inches). Laparotomy was performed by Dr. Lovett. 
The diverticulum, which was found to arise from the middle of the ileum, was resected and 
the intestinal wound sewed up. The polypus was not disturbed at the first operation, its 
blind stump being sewed off even with the inside surface of the abdominal wall. The line 
of incision, which was about 2.5 cm. (1 inch) to the left of the polypus, and 8.7 cm. (3 J 
inches) long, healed by first intention. A week afterwards the polypus was removed by 
two applications of the actual cautery. The infant was allowed to return home, but came 
back ten days later with a double pneumonia, from which it died. 



UMBILICAL HERNIA. — The ordinary umbilical hernia, which is 
simply a protrusion of a knuckle of the intestines through the unclosed 
abdominal opening left by the separation of the cord, is of very common 
occurrence. The lighter grades tend to recover spontaneously, and it is not 
advisable to operate upon them, or in fact on any umbilical hernia, until it 
has proved to be absolutely intractable, for it is an operation accompanied 



DISEASES OF THE NEW-BOKN. 427 

by considerable danger to the life of the infant. The lighter grades of 
umbilical hernia are usually easily reduced, but there is often great trouble 
in keeping them so. Various devices are employed for this purpose, but 
most of them are very unsatisfactory. At the Children's Hospital we are 
in the habit of proceeding in the following manner. 

Having gently reduced the hernia, the skin of the abdomen is so pushed 
up between the fingers that it makes a vertical fold, at the bottom of which 
lies the umbilicus. The hole should be deep enough to lay one's finger in 
it. The tension is kept up by applying a wide strip of adhesive plaster 
transversely across the abdomen. This makes a pad of flesh, which closes 
the umbilical opening and retains the intestine in place. The cure is a slow 
one, and the treatment must be continued for many months in severe cases, 
without once allowing the hernia to come out. The milder cases are also 
aided by exercises which tend to develop the abdominal muscles. This can 
be very simply effected by having the child lie on the floor, and, while the 
feet are held down, making him rise to a sitting position with the back held 
straight. This is accomplished by the rectus muscles of the abdomen, and 
if the opening is a transverse one it tends to close it. 

This case which I have here to show you (Case 173) is an infant five months old. The 
hernia, as you see, is very large, and has caused an eversion of the whole umbilical region. 
It represents an extreme grade of the disease. 

Case 173. 



y0Rk 



Umbilical hernia. Infant 5 months old. 



Cases of incarcerated and even strangulated umbilical hernia have been 
reported, but are very rare. A few have been operated upon successfully. 
The danger from all such procedures is usually considered great, but there 
has been such an advance made in the modern methods of abdominal surgery 
that the operation is looked upon with increasing favor. y^ 

INGUINAL HERNIA. — The most common forms of inguinal hernia 
that occur in young children are (1) the congenital, (2) the funicular, and 
(3) the infantile or encysted. An ordinary acquired form such as is the rule 
in the adult may be met with, but it is not so common. 



428 PEDIATRICS. 

(1) Congenital Form. — The congenital form is that variety in which 
the knot of intestine has made its way along a still patent funicular process. 
If it reaches into the scrotum it will be found completely to envelop the 
testicle. 

(2) Funicular Form. — In the funicular form, the tunica vaginalis 
having become shut off from the funicular process just above the testicle, 
the hernia comes down the patent process, but does not envelop the testicle 
as in the preceding variety. 

(3) Infantile Form. — Compared with the two forms just mentioned, 
the infantile or encysted form of hernia is quite rare, nor can it be diagnosti- 
cated with certainty without an operation. In it the funicular process has 
closed above but not below, and the intestine encased in a pouch of peri- 
toneum forces its way into the process and descends. 

The diagnosis between direct and indirect hernia has little importance in 
childhood, as the inguinal canal is so short that the rings are practically at 
the same level. Most of the hernise that you will meet in children are easily 
reducible, but you should remember that in attempting to get them back 
into the abdominal cavity you must use the greatest care, as nowhere can a 
little rough manipulation do more harm. If the hernia cannot be easily 
replaced, you must not think of leaving it where it is, simply because it 
gives rise to no alarming symptoms on the part of the child. No infant is 
safe with an irreducible hernia, and the sooner you put such a case in the 
hands of a surgeon the better. Strangulated and incarcerated herniae occur 
at times as in adults, although they are rare. They demand the same 
treatment. 

The condition with which you will most readily confound hernia is 
hydrocele. Both give rise to an elastic tumor in the inguinal region and in 
the scrotum, and in fact they resemble each other in many ways. Let me 
point out to you some of their differences. 

Hydrocele is translucent by transmitted light ; hernia is opaque. Hy- 
drocele is always dull on percussion ; hernia is usually resonant. If you 
can reduce them, hydrocele will go back slowly and noiselessly, hernia at 
the last quickly and with a gurgling sound. Hydrocele gives no impulse 
on coughing ; hernia usually does. Lastly, in feeling for the inguinal ring 
in hernia you find it filled with the neck of the tumor ; in hydrocele it is 
either empty or filled by a narrow stalk. 

Treatment. — Although the treatment of inguinal hernia, whether by 
actual operation or by the application of the usual trusses, should be in 
surgical hands, yet one method of treating these hernise is so simple and 
safe that every medical man should know about it ; in fact, in our chil- 
dren's clinics here in Boston it is much used for all children under a 
year and a half. This method is the application of a worsted truss like 
this one. 

The infant (Case 174) whom I am about to fit with this truss is eight months old. You 
see the bulging of the hernia here on the left side. Below it, feeling like another little sac, 



DISEASES OF THE NEW-BORN. 429 

is the testicle. We are, therefore, dealing with the funicular form. The mother tells 
me that she noticed the hernia when the infant was two weeks old, and that it has grown 
steadily larger. 

On laying the infant on his back on the table, you see that after a minute of gentle 
taxis the hernia can be reduced, but it comes out again with a jerk when the child begins 
to cry. 

I shall now ask Dr. Dane, who has had much experience with these cases on the surgical 
side of the hospital, and who has given me much valuable advice on the surgical bearing 
of all these cases which I have been describing to you, to reduce the hernia again and keep 
it in place. 

Dr. Dane, as you see, having reduced the hernia, and having the nurse prevent it 
from coming down by placing her finger over the inguinal ring, passes a skein of Ger- 
mantown yarn under the infant's back and brings the left-hand end of it around its left 
side, with the strands separated so as to form a loop, till it rests over the nurse's finger. 
Through the loop he puts the right unseparated end of the skein, and carries it down the 
left groin, and up on to the back, where he finishes by tying it to the middle of the skein 
as it crosses the hollow of the back just above the buttocks. As you see, he has, by thus 
threading the right closed end of the skein through the separated strands at the left end, 
made a kind of soft slip-knot which lies directly over the inguinal ring, and, when the whole 
is put on tightly, makes an excellent truss. 

Having told the mother to buy some skeins like this one, and having shown her how 
to adjust it herself, she can keep a clean truss, by washing them, on the child for a period 
of months, and if she is faithful in carrying out her part of the treatment the herniae, 
which do not depend upon an actual malformation of the ring, will probably be cured. 
If these hernise are not cured within a year, the surgical treatment of the present time is by 
operation. 

The next case (Case 175, facing page 430) which I have to show you came 
under Dr. Lovett's care at the Infants' Hospital, and had to be operated upon : 

This boy, who is now four years old, first came to the hospital two years ago. He 
then had a double inguinal hernia, both rings admitting the end of the index finger. He 
was fitted with worsted and pad trusses, but failed to return after the first few weeks. As 
you now see, the left ring has grown so much smaller that the hernia no longer descends. 
The right inguinal ring easily admits the middle finger, and when the hernia comes down 
it is quite large. Below it you can feel the testicle. As the treatment with a truss has 
failed entirely, an operation will be advised. 

In connection with this case I wish to speak of a complication that may 
exist with any hernia in male infants. If you will feel below the hernia of 
this child (Case 176), you will find no trace of the testicle, nor do you have 
any better success after you have reduced the hernia. In this instance the 
testicle is not adherent to the bowel, and has not been pushed back with it, 
as is sometimes the case, but seems never to have left the abdominal cavity. 
I shall return to this subject again when speaking of the diseases of the 
testicle. 

I must call your attention to a remarkable case that came into the hands 
of Dr. Monks, my colleague at the Boston City Hospital : 

The child (Case 177) was two years old. Two months before he was seen by Dr. 
Monks the child's mother noticed a hard bunch in the right inguinal region. This became 
larger and more painful till, at this time, it extended the whole length of the inguinal 
canal and into the scrotum. The most prominent part was midway between the external 
ring and the testicle. It was very tender, about 2.5 cm. (1 inch) long, and quite hard. 



430 PEDIATRICS. 

There was no impulse on coughing. On aspiration there were found a few drops of pus, 
but on trying to find the cavity again with a director, nothing but inflammatory tissue was 
met. Under poultices the tenderness disappeared and the tumor was reduced somewhat 
in size. 

On operation, two weeks later, the cause was found to be a hernia of the vermiform 
appendix, followed by an acute attack of appendicitis. The caput cseci and the base of 
the appendix were found inside the abdomen, and in a normal condition. An appendec- 
tomy was performed, and the child made a perfect recovery. 

Femoral Hernia. — In femoral hernia the gut escapes from the pelvis 
under Poupart^s ligament, and, making its way through the femoral canal, 
shows itself as a tumor directly under the saphenous opening. It can be 
diagnosticated at once from inguinal hernia by putting the finger on the spine 
of the pubes and noticing whether the origin of the tumor is to the outer 
or the inner side of that point. If outside, you are sure the hernia came 
through the femoral canal, no matter how far it may have extended up on to 
the abdomen. Femoral hernia is, however, extremely rare in young children, 
even in girls. In infancy the spine of the pubes, Poupart's ligament, and 
the anterior superior spine of the ilium are all much nearer together than in 
the adult. As a consequence, the femoral opening is so small and so well 
protected that it is usually impossible for the hernia to force its way through. 
Dr. Gushing, my colleague at the Children's Hospital, has reported a case 
(Case 178) of irreducible femoral hernia in which the sac contained a mass 
of omentum so matted together as to give a feeling that without special care 
might have been mistaken for that of lipoma. Such a condition must 
certainly be very rare. Dr. Cushing has described in his account of his 
operation upon this case a new incision that must prove very useful. 

HYDROCELE. — I have already spoken of the general appearance of 
hydrocele in giving you rules for differentiating it from inguinal hernia, 
with which it is often associated. 

Several anatomical varieties are met with in hydrocele, as in hernia. 
Thus, if the collection of fluid occupies a freely open funicular process, we 
have the congenital variety, and the fluid can easily be returned to the ab- 
dominal cavity by placing the child on its back and elevating the scrotum. 
This is true also of funicular hydrocele, where the fluid occupies an open 
funicular process, but is bounded below at the point where the tunica vagi- 
nalis has become walled ofl", leaving the testicle in a separate compartment 
underneath. Where the funicular process has become walled off* from the 
abdomen, but is still in communication with the tunica vaginalis, there 
may be a collection of fluid, wliicli is then known as an infantile hydrocele; 
in this form the fluid is irreducible. True hydrocele of the tunica vaginalis 
may be met with in children as well as in adults, but it is rare. 

Encysted Hydrocele of the Cord. — There is another form of 
hydrocele which often cscaj)cs recognition, but perhaps still oftener is diag- 
nosticated as hernia and treated with a truss. This is the encysted hydrocele 
of tlu^ cord. 

W in the course of the spermatic cord a hard, rounded swelling appear, 





\ 



DISEASES OF THE NEW-BOEN. 431 

and you find the testicle in its proper position in the scrotum and the 
inguinal ring clear, you are very surely dealing with a hydrocele of this 
kind. Having made your diagnosis, you can proceed boldly to its evacua- 
tion with a fine aspirating needle. You will probably draw off about 4 c.c. 
(1 drachm) of clear straw-colored fluid, and the tumor will disappear. 

A case (Case 179) of this kind was brought to the hospital last winter and entered in 
the service of Dr. Lovett. A little below the inguinal ring on the right side was a small 
tumor. The mother said that she had noticed the swelling for about a week, and the day 
before had carried the infant for advice to a local physician. He had attempted to reduce 
what he supposed was a hernia by gentle taxis. Failing in this, he gave the infant ether, 
but again was unsuccessful. The next morning, in company with an associate, he etherized 
the infant and tried unsuccessfully for an hour to effect reduction. 

The infant was then brought to the hospital for operation. The hydrocele was aspirated, 
and with the removal of a little over 2 c.c. (30 minims) of clear fluid all trace of the 
supposed hernia disappeared. 

The infant was brought back a week later, as the hydrocele had again accumulated. A 
second aspiration effected a cure. 

I mention this case in order to impress upon you how careful the 
physician who is practising among children should be not to meddle with 
cases which should at once be placed under the care of a surgeon. 

Encysted Hydeocele of the Caxal of Nuck. — Analogous to 
hydrocele of the cord in boys is an accumulation of fluid in the canal of 
Xuck in girls. The appearance of the swelling is the same in both cases, 
and the treatment should be the same. 

Teeatment. — The treatment of all forms of ii-reducible hydrocele is 
first by aseptic evacuation of the fluid with a fine canula and trocar, or by 
an aspirating needle. If this, after repeated trials, fails to effect a cm-e, 
extirpation of the sac is the only sure method, although the injection of a 
weak solution of iodine is highly recommended by many authors. It is, 
however, dangerous in children, as the occasional connection of the hydrocele 
sac with the abdomen is not to be forgotten. 

Reducible forms of hydrocele are generally to be treated by a truss, in 
the same manner as hernise, to try to effect a closure of the neck of the 
canal. If this is successful they can then be treated in the ordinary 
way. The outlook, however, is poor, and such treatment is generally un- 
satisfactory. 

As an instance of hernia and hydrocele, I have here this case (Case 180, facing page 
430) of a boy seven years old, in whom the gross appearances are the same as in the case 
(Case 179) just shown you. 

You see on reducing the hernia that the scrotum remains distended with fluid, which 
cannot be reduced into the abdominal cavity by any gentle manipulation. We are there- 
fore dealing with a true hydrocele of the tunica vaginalis. The knuckle of intestine does 
not descend to the bottom of the scrotum, because the scrotum is filled with the hydrocele. 
The hydrocele is translucent and fluctuating. 

The treatment will be to try to reduce the hernia and to cure the hydrocele by tapping. 
If these methods fail, we shall have recourse to a radical operation and treat both condi- 
tions at the same time. 



432 PEDIATRICS. 

I would here mention that cases of hernia, whether umbilical or in- 
guinal, are especially difficult to manage if the infant has some such disease 
as pertussis. There seems to be some evidence that hernia is hereditary. 
F^lizet reports eighty-five cases of hernia occurring in his practice, where, 
omitting all cases in which the father pursued some laborious trade, such as 
that of a blacksmith, he found that in 24.7 per cent, the parents had had 
similar hernise. Malgaigne reports a percentage of 29 due to heredity in a 
series of three hundred and sixteen cases of hernia. 

Infants are at times brought to our hospitals with a history of colic 
who, on examination, are found to have more or less incarceration of these 
hernias. This should impress upon you the importance of making a sys- 
tematic physical examination in every case of abdominal hernia, and of 
not taking it for granted that the symptoms are caused by indigestion. 

TESTICLE. — The testicle should descend into the scrotum at about the 
eighth month of intra-uterine life. In certain cases it does not descend, 
and if the descent does not take place within the first few years of life its 
function is lost from its becoming atrophied. It is, therefore, important in 
those cases where the testicle descends and returns to the abdominal cavity 
to retain it in the scrotum by means of apparatus. Operation for this con- 
dition is not often successful. At times an undescended testicle is found in 
combination with an inguinal hernia. A case of this kind came under my 
care about two years ago. 

A little boy (Case 181), four years old, was found to have an inguinal hernia. The 
testicle was also found at times to be absent on the side of the hernia. Sometimes the 
hernia would descend and the testicle remain in the abdominal cavity, and again the testi- 
cle would come down with the hernia. It was exceedingly diiScult to maintain the testicle 
in the scrotum, even when it was found to be there, as it would slip back with the greatest 
facility. 

I placed the case under Dr. Lovett's care, and he finally succeeded in seeing the boy 
at a time when both the testicle and the hernia were down, and in reducing the hernia 
while the testicle was kept in the scrotum. A carefully adapted truss now prevents the 
testicle from returning to the abdominal cavity and the hernia from entering the scrotum. 

Tumors of the Testis.^Wc may at birth find an enlargement of 
the testis due to sarcoma or carcinoma. The former is much the more 
common. As an illustration of this type of disease I will show you this 
infant (Case 182), who was operated upon by Dr. Lovett three months ago. 

After a normal labor, it was noticed that the infant had a swelling as large as 
an egg on the right side of the scrotum. This was at first considered to be a hydrocele, 
but, as it steadily increased in size, more active measures were employed. On bandaging, 
the skin over the tumor, which was at first normal, became so much inflamed that lead 
water had to be used as a wash. The treatment had no effect on the size of the scrotum or 
on the discomfort which it seemed to cause the little patient. The infant was now two 
weeks old. 

As the tumor had a semi-fluctuating feeling, aspiration was tried, and 2 c.c. (J drachm) 
of blood-stained serum were obtained. A second tapping gave only a little clear blood. 

The infant was then brought to Dr. Lovett for consultation. The tumor was found to 
be quite large, being 20 cm. (8 inches) in circumference, and it had nearly hidden the penis 



DISEASES OF THE NEW-BORN. 433 

in its mass. After a preliminary tapping, whicli gave the same result as the previous one, an 
operation was performed. A testicle 5 cm. (2 inches) in diameter was removed. The cord, 
which was found enlarged to a diameter of 1.2 cm. (^ inch), was removed as far up as the 
external ring, but laparotomy, in order to extirpate the cord as fully as possible, was not 
performed. The infant made an excellent recovery, and no return of the growth can be 
detected in either the scrotum or the pelvis. 

On section, the tumor was found to contain scattered throughout its mass about a 
dozen cysts of different sizes. Microscopic examination showed it to be a mixed-cell sar- 
coma with fibrous and myxomatous tissue in different parts of it. Here and there were 
scattered small areas of cartilage and a few striped muscular fibres. As you know, muscle 
fibres are found in the tumors of only two organs, the kidney and the testicle, and even in 
these they are very rare. 



MALFORMATIONS ABOUT THE RECTUM.— In speaking of 
harelip I told you in a general way how at an early stage of development of 
the embryo the intestinal canal ended blindly and afterwards by an in- 
vagination of the outside wall a communication was brought about and the 
stomodseum formed. An analogous process of development goes on at the 
other end of the intestinal tube, and results in the formation of the rectum 
and anus. The hind-gut at first ends blindly, then as it descends it is met 
by an ascending dimple, and usually these two fuse and the protodeeum is 
formed. 

As in the mouth a series of malformations may arise from a failure in 
the completion of this process, so in the anal region we may meet with a 
similar series. The rectum may have come into its normal relations and 
the anal depression have failed to form, or it may have gone the whole of 
the distance between the end of the intestine and the skin and yet the 
final step, the fusion of the membranes, have failed to take place. To both 
of these, and to any intermediate condition, the name of imperforate rectum 
is given. On the other hand, with the rectum and the anus fused we may, 
nevertheless, find a thin parchment-like membrane spread over the external 
orifice just where the skin and the mucous membrane join. This is called 
imperforate anus. 

When an infant is born the physician should carefully examine it, in 
order to determine whether it has any malformation. The most important 
malformations which it is necessary to recognize are those at the anus. 
Unless an infant has a passage of meconium soon after its birth, an exam- 
ination should be made in the rectum with the finger, and if the anal opening 
is found to be closed, either just at the outlet or higher up, we must consider 
what is to be done to relieve this condition. If nothing but a web obstructs 
the anus, we can easily break it through with a director and then dilate the 
orifice with the finger. If there is more than the thinnest bulging mem- 
brane, a cutting operation will have to be done, and perhaps a severe one. 
The general principles are to begin with a staff in the bladder, and, using 
this as a ouide, to make a careful and svstematic dissection in search of the 
missing gut. If we fail in this, we should perform tlie operation known 
as Littre's, which consists in opening the sigmoid flexure in the inguinal 

28 



434 PEDIATRICS. 

region and making an artificial anus there. There is a still more severe 
form of operation, in which an attempt is made to cut through the sacrum 
and make the gut open there, but it has many practical objections in very- 
young infants. 

Here is a specimen (Fig. 89) taken from an infant, a patient of Dr. 

Fig. 89. 




Imperforate rectum. Male, 14 days old. Warren Museum, Harvard University. 

John Ware's. It died on the fourteenth day of its life. From the time of 
its birth it had constant vomiting and much distress. The autopsy showed 
the lower part of the small intestine and the whole of the large intestine to 
be acutely inflamed, and that there was ulceration of the latter. You see 
that the upper and lower portions of the intestine terminate in a cul-de-sac 
a short distance from the anus and are separated for about 0.85 cm. (J inch). 
The large bulging mass above represents the rectum distended with 
meconium and separated from the anal opening by an isthmus of solid 



DISEASES OF THE NEW-BORN. 435 

connective tissue. The smaller mass in front (to the left in the picture) is 
the bladder. 

OCCLUSION OP THE VAGINA.— Sometimes we find a thin gray 
velum extending across the mouth of the vagina from just below the 
urethral opening to the posterior commissure and blocking up the vagina. 
It may be complete or partial. This condition should be dealt with while 
the infant is still young, as if left until puberty it will cause a retention of 
the menses, and, moreover, by that time will have become much thicker and 
perhaps quite vascular. It is easily broken through in the young child, 
and if a piece of carbolized cotton be put between the torn edges to prevent 
their adhering, the malformation can be cured permanently. Atresia from 
inflammation of the labia is said to occur in rare instances. 

HYPOSPADIAS. — The malformation known as hypospadias is the 
result of an arrest of development in the formation of the urethra and of 
the corpus spongiosum. The urethral groove should normally be converted 
into a canal by the growth and joining together of its sides. This process 
begins at the base and extends to the end of the penis. By an interruption 
of this process the urethra may be brought to an end and open at any point 
between the peno-scrotal angle and the base of the glans. In the most 
common forms of hypospadias the glans alone is imperforate. 

Treatment. — The treatment is wholly by plastic operation, and it 
requires the most delicate surgery to obtain a good result in the face of the 
many serious obstacles that this malformation presents. 

EPISPADIAS. — The malformation of epispadias, in which the urethral 
canal opens upon the dorsum of the penis, is still more difficult to deal with 
than is hypospadias. It is commonly associated with extroversion of the 
bladder, and is very rare. 

A partial plastic operation and the wearing of some form of urinal con- 
stitute about all that can be done for these cases. 



436 PEDIATRICS. 




LKCXURE XX. 

THE EXTREMITIES.— GENERAL DISEASES. 

FINGERS. — Various malformations of the extremities are met with in 
new-born infants, and I happen to have one of these to show you to-day. 

This infant (Case 183) has six fingers on each hand instead of five. 

This is only one of a type of malformations which you are liable to 
^ , go encounter. Another malformation of this kind, called 

webbed fingers, is quite common. 

TOES. — Infants are at times born with exh^a 
toes and webbed toes, and it becomes a surgical ques- 
tion to determine whether they shall be operated upon. 
This, of course, is a question of orthopaedics, and is 
one which we need not deal with except so far as to 
appreciate the importance of preparing the foot prop- 
erly for future use. 
Infant's hand with six The greater freedom of movement required for 

fingers. ^j^g fingers, and the fact that the hand is always 

in sight, render surgical interference much more necessary in malformations 
of the hand than in those of the foot. 

Congenital hypertrophy of the feet and hands, and congenital deficiency 
of one or more extremities, may be spoken of in this connection, but are too 
rare to be more than referred to. 

These malformations have been thoroughly described by Thomas Annan- 
dale, and I shall refer you to his work on this subject for information re- 
garding them. 

CLUB-HAND AND CLUB-FOOT.— Club-hand and club-foot are 
congenital malformations which may be due to an undeveloped condition of 
either the bones, the ligaments, or the muscles. In the more simple forms 
the extremity is pulled into the malposition by the action of contracted 
muscles and tendons, while in the severe forms the bony framework may 
be so misshapen that the separate segments are almost unrecognizable. 
Club-hand is often accompanied by absence of the radius. 

Treatment. — The treatment of this class of deformities is, of course, 
purely in the province of the orthopaedic surgeon. All that I wish to do in 
referring to them is to suggest to you how much may be accomplished by 
simple manipulations with the hand. The mother should be instructed to 
rub the foot and leg twice daily, and to make firm pressure against the 
shortened muscles by trying to bring the hand and foot into the normal 



DISEASES OF THE NEW-BORN. 437 

position. I have seen light cases cured by this simple means, and even 
moderately severe ones so much benefited that subsequent treatment with 
orthopaedic apparatus became much easier. 

CONGENITAL DISLOCATION OF THE HIP.— Congenital dislo- 
cations of all the joints are sometimes found, the most frequent and most 
important being dislocation of the hip. This is now thought to be caused 
by a faulty development of the acetabulum and the head of the femur. The 
symptoms are of a kind that readily escape notice during infancy, and are 
first seen when the child should begin to walk. It is then noticed, if he 
can hold himself on his feet at all, that the abdomen is very prominent, 
the back arched, and the buttocks seemingly enlarged : at least this is the 
case if the deformity is bilateral, which is the form usually met with. On 
examining the joint we find that the trochanter is above Nekton's line, but 
it can by traction on the leg be drawn down to its proper place without 
causing any discomfort to the child. If the deformity is unilateral, one leg 
will appear shorter than the other, and the child will walk with a rolling 
limp. This condition should be carefully looked for when an infant at the 
age of fourteen or fifteen months has made no especial attempt to walk, or 
when on attempting to do so it does not succeed. 

As operative treatment has not proved very successful in these cases and 
is not to be employed until the child is over three years old, the best method 
of treatment is by massage. If the disease is unilateral it should in addi- 
tion to the massage be treated with a high shoe. 

CONGENITAL DISLOCATION OP THE KNEE.— Next m order 
of frequency to congenital dislocation of the hip, but rare in comparison, is 

Case 184. 




Congenital partial dislocation of the knee. Female, 5 months old. 

a dislocation, or rather a partial dislocation, of the knee. In this condition 
the tibia is found riding forward upon the femoral condyles, so that the 



438 PEDIATRICS. 

knee-joint can readily be put into hyperextension and the toes made to 
point towards the forehead. Here is a case (Case 184) which illustrates 
this condition. 

The infant is five months old, and was delivered with instruments after a long labor. 
It was a head presentation. As you see, there is a remarkable range of motion at the knee. 
Not only can I put it into hyperextension, but I can move it considerably from side to side. 
This abnormal mobility is due to a very lax condition of all the tissues about the knee, and 
especially of the lateral ligaments. It has been treated, its mother tells me, by a plaster 
bandage for about a month, and no improvement has taken place. "We should not be at 
all surprised at this result, when we consider that keeping the knee immovable simply tends 
to increase the already existing atrophy. 

A far better form of treatment is the application of a light steel support which will 
check all lateral motion and by means of a " stop joint" at the knee will allow flexion but 
will prevent hyperextension. This apparatus, together with systematic massage, will prob- 
ably effect a cure. 

BIRTH PARALYSIS. — Birth paralysis will be considered in connec- 
tion with diseases of the nervous system. It may be present either in the 
muscles of the face or in those of the extremities, and is due to pressure 
upon the nerves made by the forceps or by too great traction. 

CONGENITAL OBLITERATION OP THE BILE-DUCTS.— One 
of the rarer forms of congenital malformations in new-born infants is 
represented by the obliteration of the bile-ducts. The most extended work 
which has appeared in the literature of this subject is that of Dr. John 
Thompson, of Edinburgh, whose valuable thesis I have used in my descrip- 
tion of the disease. 

Symptoms. — The infants who are born with this disease are either 
icteric at first or become so within the first few weeks of life. They often 
appear otherwise healthy and well nourished. In some cases there is a 
discharge of normal meconium followed by colorless dejections. In other 
cases the fsecal movements are clay-colored from the very first and remain 
so. The urine is deeply stained with bile. The jaundice is of a dark- 
greenish tinge, lasting until death. Spontaneous hemorrhage from the 
umbilical cord commonly occurs within the first two weeks, and in other 
localities in those infants who survive this early period. The liver and 
spleen are increased in size. If the infants survive for some months they 
become more or less emaciated. Convulsions and vomiting are apt to occur, 
and death usually takes place from exhaustion or from some trifling inter- 
current disease. 

Pathology. — There are a number of different morbid processes which 
have been supposed to produce this pathological lesion of the ducts. Each 
of these processes has in certain cases, in all probability, had much to do 
with causing the disease, but it is usually the combination of one or more 
of them which must be considered in determining its etiology. Thus, the 
results of intra-uterine peritonitis, by compressing the ducts, or by being 
a source of inflammation which has spread to the walls of the ducts, may 
finally cause their obliteration. A primary inflammation or lesion of the 



DISEASES OF THE NEW-BOEX. 439 

ducts themselves may produce this result, or it may arise from an actual 
arrest or defect of development. In this connection congenital syphilis should 
be referred to as in some cases producing lesions of the ducts, but this and 
other causes do not necessarily play an important part in the disease. 

The complete discussion of the causes of congenital malformation of the 
bile-ducts would hardly have a place in a general work on clinical medicine, 
but it is sufficient to say that in the great majority of cases the evidence is 
in favor of defective development as being the chief cause. This malfor- 
mation probably affects to a considerable extent the walls of the ducts, and, 
as Thompson has stated, it consists in the narrowing of their lumen. The 
interference which is thus caused to the outflow of bile gives rise to a 
catarrhal condition which finally blocks and obliterates the ducts^ owing to 
the inflammatory process spreading to the walls of the ducts and the gall- 
bladder. This progressive inflammation goes on slowly spreading, the local 
condition gradually becoming worse during many months if the patients live. 
The obliterated ducts or gall-bladder, or portions of them, may entirely 
disappear, not even leaving a distinct band of fibrous tissue to indicate their 
original position. The obliteration generally becomes complete at a variable 
but early period of intra-uterine life : occasionally it does not occur imtil 
after birth. The occurrence of peritonitis is probably in most cases second- 
ary to the blocking of the ducts. 

When the lumen of the duct has become so narrowed that the bile does 
not pass freely into the intestine, a cirrhotic condition begins in the tissues 
of the liver, and as it goes on interferes with the fimctions of that organ. 

At the post-mortem examinations of these cases the liver usually is 
found to be much enlarged and its tissues to be increased in consistency : it 
is of a dark-brown color, owing to the presence of numerous masses of 
inspissated bile in the smaller bile-ducts. In a large number of cases 
there is found a complete obliteration of some part or parts of the hepatic, 
common, or cystic ducts, or of the gall-bladder, while, with very few ex- 
ceptions, implication of the blood-vessels is conspicuously absent. 

In speaking of the explanation which may be given for the occurrence 
of the symptoms which I have just mentioned, Thompson remarks that the 
reappearance of the disease in several members of the same family can be 
explained only by the theory that a congenital defect of development is in 
these cases the cause of the malformation. The fact that the onset of the 
jaundice is not contemporaneous with the blocking of the bile-ducts, and 
usually begins several days after birth, he explains as the effect on the 
hepatic cells produced by the great changes in the hepatic circulation ^^•hioh 
occur in new-born infants. The presence of colored meconium in some 
cases and of only white discharges in others is due to the blocking of the 
ducts having occurred at different periods of intra-uterine life. 

When in combination with the colorless fa?cal discharges green material 
is passed during the progress of the disease, this occurrence is in*obably due 
to the chemical action on the contents of the intestine, produced in various 



440 PEDIATRICS. 

ways, one of which may arise if mercury has been administered. The 
tendency to spontaneous hemorrhages may be due to the occurrence of a 
condition of chronic blood-poisoning, since the arrest of the outflow of bile 
damages the liver to such an extent that its functions are interfered with 
and organic fluids of a poisonous nature may thus pass into the circulation. 
The enlargement of the spleen, the convulsions, and the vomiting are prob- 
ably more or less connected with this same condition of blood-poisoning. 
The fact that the children live as long as they do, and usually do not 
become emaciated in the early days of life, is to be explained on the ground 
that the presence of bile in the intestine is not absolutely necessary for 
digestion. When the nutrition and general health begin to suffer, it is 
probably due to the interference which the secondary changes in the tissues 
of the liver are causing with the more important functions of that organ. 

Treatment. — The treatment must necessarily be symptomatic, there 
being no known means by which we can counteract the results of this mal- 
formation. 

Congenital Obliteration of the Intestine. — I shall merely refer 
to a malformation which is represented by an obliteration of the intestine. 
Malformations of this kind may arise from constrictions of the parts af- 
fected by fibrous bands, probably the remains of peritoneal adhesions. 

Congenital Malformations of the CEsophagus and Stomach. — 
Congenital malformations of the oesophagus and stomach are rare, and can 
best be described in connection with diseases of these parts. 

MALFORMATIONS OP THE HEART AND THE BLOOD- 
VESSELS. — I shall defer what I have to say concerning the various anom- 
alies of the heart and blood-vessels until later (Division XVIL, p. 1020). 

ASPHYXIA. — The earliest pathological condition which is brought to 
our notice at birth, and one which requires immediate treatment, is asphyxia. 
This condition, which is a failure of the circulatory mechanism to assume 
its extra-uterine function of oxygenating the blood, endangers the life of the 
infant from carbonic acid poisoning. It may arise either from mechanical 
pressure, as from winding of the cord around the neck, from an incomplete 
expansion of the pulmonary alveoli, atelectasis, or from other causes con- 
nected with the imperfect oxygenation of the blood, of which we have 
very little knowledge. In any case the cause, if known, must be quickly 
removed. This class of cases belongs so directly to the province of obstet- 
rics that it need hardly be more than mentioned in a course of lectures on 
pediatrics. Prompt measures for performing artificial respiration, as by 
Crede's method, and the stimulation of the pneumogastric nerve by the 
application of heat, cold, and electricity, should be borne in mind : they are 
well described in Dr. Edward Reynolds's work on practical midwifery. 

ACUTE FATTY DEGENERATION OF THE NEW-BORN (BuhPs 
Disease). — An affection which has been called acute fatty degeneration of 
the new-born was described by Buhl in 1861. It is not a disease of common 
occurrence, and its etiology and pathology have not yet been satisfactorily 



DISEASES OF THE NEW-BORN. 441 

determined. Eunge^ of Dorpat, has written more fully on this disease than 
any other author, and I am indebted to him for the careftd. description 
which he has made of the affection and the literature which he has collected 
concernuig it. 

As the anatomical diagnosis can be made only by using the microscope, 
the disease has probably often been overlooked, and the cause of death 
ascribed on the one hand to inanition and on the other to such especial forms 
of hemorrhage in the new-born as omphalorrhagia and melsena. If the 
numerous causes of hemorrhage from the cord had been more carefully 
examined anatomically, the disease would probably not have remained so 
long unknown. 

Symptoms. — The infants who are affected by this disease are usually 
born in a condition of extreme asphyxia without any apparent cause for it. 
Attempts at resuscitation are, as a rule, only partially successful, and at times 
not at all so, many of the cases dying at once. Diarrhoea is commonly 
present, and is often accompanied by blood from the rectum. There is 
sometimes vomiting of blood. Often, after the cord has separated, there 
may be a parenchymatous hemorrhage, which, although small in amount, is 
at times sufficient to cause death. There is usually a bluish color of the 
skin, which changes gradually to yellow or a mixture of yellow and blue. 
Hemorrhages occur frequently in the skin, the conjunctivae, the mucous 
membranes of the mouth and nose, and sometimes the outer ear. Icterus 
may be present in these cases, and at times may become intense. Sometimes 
oedema occurs, and without any noticeable rise of temperature there may be 
a rapid collapse, followed by death, commonly within the first fourteen days 
of life. These symptoms are not always so well marked as I have just 
described them. The external hemorrhages may not occur, and the cyanosis, 
slight at first, may rapidly increase and be followed by sudden death. This 
sometimes happens so quickly that we are reminded of the conditions which 
are met with in cases of death by violence. 

Diagnosis. — A definite diagnosis cannot be made without a careful 
microscopic examination. The disease must not be confounded with phos- 
phorus or arsenic poisoning, where the organs undergo similar pathological 
changes. The history of the case and a chemical examination of the organs 
will enable you to eliminate these other causes of fatty degeneration. The 
differential diagnosis between this disease and cases of sepsis in which 
hemorrhages and parenchymatous changes occur is very difficult. Where 
the vessels of the cord are affected, we must in most cases consider the cause 
to be septic ; where the cases occur in groups, as is seen at times in hospitals 
or other places where a number of infants are gathered together, this same 
cause must be suspected ; also where putrefactive changes have progresseil 
rapidly in the cadaver we should be inclined to regard the case as one of 
septic poisoning, as these changes, according to Hecker, do not occur in the 
specific disease called fatty degeneration. 

Fatty degeneration at times simulates so closely the appearances caused 



442 PEDIATRICS. 

by death from suffocation that its presence becomes a question of great 
importance from a medico-legal stand-point. The cyanosis, the condition 
of the lungs, and the ecchymoses, also the absence macroscopically of other 
organic changes, can easily suggest suffocation. For this reason in all 'cases 
of death among new-born children where there is a suspicion of asphyxia, a 
careful microscopic examination should be made of all the organs. 

Prognosis. — The prognosis in this disease is very unfavorable : all the 
cases in which the symptoms are pronounced die. It is possible that the 
milder forms of the disease can recover, but as yet we do not know enough 
about this class of cases to state what proportion of them lives. 

Etiology. — The etiology of acute fatty degeneration of the new-born 
is very obscure. The disease occurs in animals as well as in human beings, 
but the investigations made by different observers both on animals and on 
infants are so varied in their results that we cannot at present consider that 
we know much about the cause of the disease. It is significant, however, 
that Buhl in his classic description of the disease states emphatically that 
the vessels of the cord are not affected, so that if it is due to sepsis the sepsis 
must have occurred in intra-uterine life through the mouth, the intestinal 
canal, or the umbilicus, but Avithout producing any change in the umbilical 
vessels. This can scarcely be considered probable. We know nothing 
concerning the etiology of this disease, not even whether it is of intra- or 
extra-uterine origin. 

Pathology. — The pathological conditions which represent the disease 
consist of a parenchymatous inflammation, followed by a fatty degeneration 
of the tissues of the heart, liver, and kidneys, and hemorrhages in the 
various organs. The post-mortem examination of infants dying of this 
disease, as a rule, shows the following changes. The cadaver is livid and 
usually icteric. Hemorrhages and oedema are often found in the skin. The 
umbilicus and the tissues surrounding it are at times stained with blood, but, 
as a rule, are otherwise normal. The umbilical vessels are in most cases 
normal. These hemorrhages are especially found in the dura and pia mater, 
in the pleura and pericardium, and in the connective tissue of the medi- 
astinum : they also occur in the thymus gland, in the peritoneum, in the 
muscles, and in most of the mucous membranes. 

The brain is found to be soft, usually full of blood, and, if icterus is 
present, is stained yellow. 

The lungs often show hemorrhagic infarction, and in the bronchi bloody 
mucus or pure blood. The alveolar epithelium is in a condition of fatty 
degeneration. 

The muscles of the heart are friable. In the early stages they are rigid 
and dark red, while in the later stages they become softer and paler. In 
almost all of them the process of fatty degeneration is found. 

In recent cases the tissues of the live7^ are blood-red, while in the later 
stages they are pale and icteric. The liver-cells contain fat-drops and 
granules of biliary coloring matter. 



DISEASES OF THE NETV-BOEX. 443 

The spleen is usually found to be enlarged^ and its parenchyma is soft 
and almost fluid. 

Hemorrhages may be fomid in the walls of the stomach and intestine j 
and their cavities are often found to be filled with blood. 

Multiple hemorrhages are found in the parenchyma of the Jddney. The 
cortex is swollen in the early stages, is filled with blood, and is pale and 
yellowish. The epithelium of the convoluted tubules shows marked fatty 
degeneration, and the canals are often filled with fatty degenerated material. 

The process of fatty degeneration does not in all cases affect all the 
organs. In some the changes may be absent or a parenchymatous condition 
may be present. 

Treatment. — From what I have said concerning this disease you will 
readily understand that the treatment is usually unsuccessful. Stimulants 
should be used and the food carefully regulated. 

Literatuee. — You may perhaps like to know the sources (Table 90) 
from which Eunge has obtained his facts in describing the acute fatty 
degeneration of the new-born. 

TABLE 90.' 

1. Hecker, y., u. Btthl, Klinik d. Geburtskunde, 1861, Bd. i. S. 296. 

2. Hecker, v., Monatsschrift f. Gebiirtskunde, Bd. xxix. S. 321; Bd. xxxi. S. 197; 

Bd. xxxii. S. 197. 

3. Hecker, y., Arch. f. Gynak., 1876, Bd. x. S. 537. 

4. ^It'LLER, P., Die acute Fettentartung der Neugebornen, Handb. der Kinder- 

krankbeiten, Yon Gerbardt, 1877, Bd. ii. S. 186. 

5. CoHXHEiM, Yorlesungen iiber allgem. Patbologie, 2. Aufl., Bd. i. S. 651. 

6. Herz, Oesterr. Jabrb. f. Padiatrik, 8. Jabrg., 1877, S. 139. 

7. EuxGE, Max, Cbarite-Annalen, 7. Jabrg., 1882, S. 720 u. 727. 

8. Ft'^RSTENBERG, Yircbow's Arcb., 1864, Bd. xxix. S. 152. 

9. EoLOEF, Yircbow's Arcb., 1865, Bd. xxxiii. S. 553. 

10. RoLOFF, Yircbow's Arcb., 1868, Bd. xliii. S. 367. 

11. BoLLiXGER, Yircbow's Arcb., 1873, Bd. Iviii. S. 329. 

12. Birch-Hirschfeld, Handb. der Kinderkrankbeiten, Yon Grerbardt, Bd. iv., 2, 

S. 707. 

13. Frtedberger, Praxz, u. PrOhxer, Eugex. Lebrbiicb d, spec. Patbologie u. 

Tberapie d. Haustbiere, III. Auflage, 1892, Bd. ii. S. 16 ff. 

INFECTIOUS H^MOGLOBIN^MIA OF THE NEW-BORN 
(Winckel's Disease). — Infectious hsemoglobinsemia is an affection which is 
met with in new-born infants usually in the early days of life, and, as a 
rule, arises as an endemic disease in hospitals. The specific micro-organism 
which produces it has not yet been discovered, yet the fact of its endemic 
character and the changes which are produced in the blood warrant us in 
supposing that it is an infectious disease. Although it had been descrilxxi 
at an earlier date, yet the most systematic description of it which had 
appeared up to the year 1879 was that by AVinckel, who in that year 
reported twentv-three cases of an endemic affection observed by him at the 
Dresden Lying-in Hospital. The disease was characterized by extreme 



444 PEDIATRICS. 

cyanosis, icterus, hsemoglobinuria, somnolence, rapid collapse, and the ab- 
sence of fever. 

Although in many respects it resembled closely the acute fatty degenera- 
tion which I have just described to you, yet it had such characteristic 
symptoms and conditions of its own that it cannot, until further light shall 
have been thrown on the subject, be separated from that disease. 

I am indebted to Runge for a description of this disease. An analysis 
of WinckeFs cases shows that it usually begins on the fourth day of life, 
and that it may attack strong, well-developed infants. The course of the 
affection is very rapid, its average duration being about thirty-two hours. 
Twenty-five and a half per cent, of all the children born at the time 
when this epidemic occurred had the disease, and of these nineteen per cent, 
died. 

Symptoms. — The first symptoms were generally restlessness and cyano- 
sis, not only of the face but also of the body and extremities, and especially 
the back. The color increased progressively until it became a deep blue. 
To this was added an icteric color, which when death did not occur within 
twenty-four hours became very marked. The respiration was rapid; the 
pulse was not especially increased in rate. The rectal temperature never rose 
higher than 38.1° C. (100.6° F.). The skin generally felt cool. Vomiting 
and diarrhoea occurred in some cases. The most striking symptom was the 
appearance of the urine. It had a pale-brownish color, and was passed fre- 
quently, and often with considerable straining. An examination showed 
that the color was due not to bile, but to haemoglobin. In the sediment 
were found numerous epithelial cells from the walls of the kidney, granular 
casts with blood-corpuscles adherent to them, micrococci, masses of detritus, 
and urate of ammonia. A small quantity of albumin was present. Later 
in the disease convulsions occurred, followed rapidly by death. It was 
noticed that if the skin where the cyanosis was most marked was scratched 
and then pressed hard, a tenacious, almost black-brown fluid exuded. An 
examination of the blood showed a marked increase of leucocytes and 
numerous granules. 

In other cases besides those of Winckel's where the blood was examined 
the condition was found to be one of hsemoglobinsemia. The percentage of 
haemoglobin was high, and free haemoglobin was found in the blood-serum, 
while the erythrocytes were greatly reduced in number, at times amounting 
to only 1,700,000 or even less. 

Pathology. — A careful post-mortem examination of Winckel's cases 
showed that there was cyanosis of the external and internal organs. Except 
in one instance, no pathological condition of the vessels of the cord was 
described. 

The cortex of the kidney was found to be wider than normal, to be of a 
brownish color, and to present numerous minute hemorrhages. In places 
the pyramids were entirely black-red in color, and in other places numerous 
black streaks were found which converged to the papillae. This color was 



DISEASES OF THE NEW-BORN. 445 

caused by the filling of tlie straight tubules with granules of haemoglobin. 
Intact erythrocytes were never found. 

The bladder was found to contain greenish-brown urine. 

The spleen was strikingly enlarged and hard. Its length was about 7.5 
cm. (3 inches), and its weight 25 grammes (| ounce). It was black-red in 
color, and on section the surface was smooth. Microscopic examination 
showed a considerable accumulation of brownish coloring matter, partly 
free and partly in the pulp-cells. 

In addition to these appearances in special organs, minute hemorrhages 
were found in nearly all the organs, but especially in the pleura, pericardium, 
endocardium, mucous membranes of the stomach and small intestine, and 
kidney : they were also found in the dura and pia mater and under the 
capsule of the liver. The lymph-follicles were swollen, especially Peyer's 
patches and the mesenteric lymph-glands. 

A microscopic examination showed fatty degeneration of many impor- 
tant organs, especially the liver, and at times of the muscles of the heart. 

The bacteriological examinations were, as a rule, negative, especially as 
regards the tissues of the intestine. Clumps of bacteria were found only 
once in the liver and once in the kidney. 

Etiology. — The etiology of this disease is obscure. Winckel had 
careful examinations made of the organs chemically for poisons, such as 
phosphorus, arsenic, and chlorate of potash, but with negative results. 
Examinations in regard to carbolic acid poisoning have also been made in 
these cases, with negative results. 

The resemblance of this disease to acute fatty degeneration of the new- 
born is very striking. Most of the symptoms are common to both diseases. 
Larger hemorrhages are also not uncommon in this disease, but are not so 
marked as in acute fatty degeneration. The striking points of difference 
are the presence of hsemoglobinuria, and that large numbers of cases are 
affected at the same time in infectious hsemoglobinsemia, while these condi- 
tions have not been found to occur in acute fatty degeneration. In studying 
the literature of this disease we find a number of observations by different 
authors. Dr. W. S. Bigelow describes an epidemic at the Boston Lying-in 
Hospital in which the chief symptoms were a dark color of the skin resem- 
bling somewhat that produced by the administration of nitrate of silver, 
hsemoglobinuria, diphtheritic deposits on certain of the mucous membranes, 
and dark brown faecal dejections. In this epidemic ten infants were attacked 
and eight died, the average duration of the disease being five days. In one 
of these cases phlebitis umbilicalis occurred. Similar cases have been 
reported by Parrot and Herz in which the urine was brown and strongly 
tinged with blood and the kidneys and liver showed the condition of fatty 
degeneration. 

Epstein, of Prague, mentions similar cases where prominent features 
were the thickening of the blood, which made it impossible to get a drop to 
examine, and the dark brown-red color of the urine. Epstein thinks that 



446 PEDIATRICS. 

this disease is a septic process which probably starts in the gastro-enteric 
tract. He believes that he can controvert the apparent absence of fever by 
the fact that in the diseases of new-born infants great and sudden variations 
of temperature occur, and in consequence the temperature, for its record to 
be of value, should be taken very often. 

Whether this is so or not, the disease has certain peculiarities, pointing in 
some cases to an apparent relation with sepsis, and in others to acute fatty 
degeneration. 

The obscurity as to the etiology of the disease has been rendered still 
greater by the incomplete examinations which have been made of this class 
of cases, with the exception of those by Winckel and Birch-Hirschfeld. 

Treatment. — The treatment should be the administration of oxygen 
and stimulants, and forced feeding by means of a dropper where the infant 
is too weak to suck. 

Literature. — I have placed in this table (Table 91) the literature 
which Runge has made use of in his description of this disease. 

TABLE 91. 

1. Winckel, Deutsche Med. Wochenschrift, 1879, Nr. 24, 25, 33, 34, 35. 

2. BiRCH-HiRSCHFELD, Deutsche Med. Wochenschrift, 1879, Nr. 36. 

3. BiRCH-HiRSCHFELD, Haiidbuch der Kinderkrankheiten, von Gerhardt, 1880, Bd. 

iv., 2, S. 702. 

4. Epstein, Prager Med. Wochenschr., 1879, S. 343 

5. Sandner, Miinch. Med. Wochenschr., 1886, Nr. 24. 

6. Strelitz, Archiv f. Kinderheilkunde, 1890, Bd. xi. S. 11, and Baginsky, Berl. 

Klin. Wochenschr., 1889, Nr. 8, same case. 

7. Baginsky, Lehrbuch der Kinderkrankheiten, lY. Auflage, 1892, S. 59. 

HEMORRHAGE IN EARLY LIFE. — Spontaneous hemorrhage oc- 
curring at some period during the early years of life is not uncommon. 
These hemorrhages may occur either in the skin or from some trifling 
traumatic lesion, or they may take place in various internal organs, and 
especially from the mucous membrane of the mouth and the gastro-enteric 
tract. A definite division of this class of cases has never been thoroughly 
made, so that the subject has always been somewhat involved in obscurity. 
The probability is that these spontaneous hemorrhages are simply symp- 
tomatic of different specific diseases, and that as our knowledge of these 
diseases increases we shall find it necessary to make a clear distinction 
between cases which now are spoken of under one head. The propriety of 
separating cases of spontaneous hemorrhage which occur in the early days 
and weeks of life from those which arise later has been shown by Dr. Town- 
send. He has by a series of observations corroborated the now generally ac- 
cepted opinion that the hemorrhages which occur in the new-born should 
be separated from those met with in connection with the haemophilia of 
a later period of childhood and of adults. He has called this disease the 
hemorrhagiG disease of the new-horn. The hemorrhages which occur in 
new-born infants are so general in their distribution, and yet so uniform in 



DISEASES OF THE NEW-BOEN. 447 

their general symptoms, that they can well be classed under this one heading. 
These hemorrhages occurring in the early weeks of life run a definite course, 
and end in death or in complete recovery. The self-limited nature of this 
affection corresponds to what is seen in the acute infectious diseases, and 
suggests a relationshi^D to them. The hemorrhage may arise from the 
gastro-enteric tract, from the mouth, the nose, or the umbilicus, also from 
the skin, and in the latter case may show itself in the form of ecchymoses. 
Again, it may occur in the form of hemorrhages in the abdominal cavity, 
the meninges of the brain, the pleura, the lung, and the thymus gland. 

Dr. Townsend has collected fifty cases of this disease, and has tabulated 
the sources of the hemorrhage, as follows (Table 92) : 

TABLE 92. (Townsend.) 
Locality. Cases. 

Intestines 20 

Stomach 14 

Mouth 14 

Nose 12 

Umbilicus 18 

Ecchymosis in skin 21 

Scratch of skin 1 

Cephalhsematoma 3 

Meninges 4 

Abdominal cavity 2 

Pleural cavity 1 

Lung 1 

Thymus gland 1 

Erom the gastro-enteric tract, nose, and umbilicus, accompanied by ecchy- 
mosis in the skin 3 

From the gastro-enteric tract alone 19 

Erom the umbilicus alone 3 

Erom ecchymosis in the skin alone 6 

The mortality in these cases was 62 per cent. The bleeding first showed 
itself in all but three within the first seven days of life, the exceptions being 
on the eighth, ninth, and fourteenth days. The hemorrhage in the majority 
of these cases began on the second or third day, thirteen starting on the 
second and sixteen on the third day, while only eight began on the fourth 
and two on the first day. One-half of the fatal cases lasted one day or less, 
and all the others died within a week, except one case, in which death took 
place from the effects of the hemorrhage on the eighth day and several days 
after the bleeding had ceased. The cases that lived recovered within nine 
days, and two-thirds of them Avithin five days. 

The cases of pseudo-menstruation which occur not uncommonly in the 
early days of life should not be included in the cases which are classed under 
the heading of hemorrhagic disease. The hemorrhagic disease is apparently 
a general and not a local one, and is found more frequently in hospitals than 
in private practice. This fact is well exemplified by comparing the per- 
centage of hemorrhagic cases which occurred among 7225 infants observed 
in the Boston Lying-in Hospital and its out-patient depai'tment. The per- 



448 PEDIATRICS. 

centage of the disease in the hospital itself was represented by .57, while .10 
represents the proportion outside of the hospital. In Townsend^s fifty cases 
the proportion of females to males was as 20 to 30. In four of Townsend^s 
cases the hemorrhage took place in several places as well as at the base of 
the cord, but the patients recovered and the cord separated, in one case 
in two days and in the other three in four days after the cessation of the 
disease, without a fresh hemorrhage occurring. 

In fourteen of these fifty cases the temperature was carefully observed, 
and in all but two was found to be elevated at first from 38.3° C. (101° F.) 
to 39.5° C. (103.1° F.), and in one case to 40.1° C. (106° F.). After the 
cessation of the hemorrhages the temperature was normal, and often sub- 
normal. 

To recapitulate : it would seem that we are warranted in considering the 
disease as one of a general nature, and infectious, for the following reasons. 
(1) It occurs usually in hospitals. (2) It is self-limited in its course, 
and, although a dangerous disease, may be recovered from in one or two 
weeks completely and never return. (3) The temperature is raised during 
the continuation of the chief symptoms, and becomes normal or subnormal 
when the hemorrhage has ceased. 

Ritter at the Prague Foundling Hospital has also noticed a great 
preponderance of cases occurring in hospital deliveries over those which 
were met with outside of the hospitals. 

In connection with the hemorrhage which occurs in the gastro-enteric 
tract, the tar-color of the intestinal dejections, arising from the hemorrhage 
taking place high up in the intestine, is noticeable. The resemblance of the 
color of the dejections to that of meconium may cause the disease to be over- 
looked. A slightly pink tinge on the napkin around the dejection is often, 
however, seen, and where there is a doubt as to whether the stain is from 
blood or not, it can usually be determined by means of the microscope. 
Where the corpuscles have become disintegrated, as at times occurs, the 
hsemin crystals may be recognized by means of a simple test which I shall 
speak of later. The post-mortem examination which was made in nine of 
these cases throws no additional light upon the nature of the affection. The 
source of the hemorrhage was found, but in no case were there any gross 
lesions of the mucous membrane or the blood-vessels. In all these cases 
the infants looked very ansemic. In one case cultures were made by Pro- 
fessor Councilman from the blood, with negative results. We do not know 
what the cause of this disease is, but it is probable that in the great majority 
of cases it has an infectious origin. 

I will now show you a case (Case 185) which is especially interesting, as 
it shows an unusual result of the blood examination. 

The infant is three days old, and presents a blanched appearance of the skin, with stains 
on the napkin around the intestinal discharges. These stains have been examined in the 
following way. A drop of the semi-liquid dejection was mixed with a little glacial acetic 
acid and a few crystals of common salt on a glass slide and heated to boiling. On drying 



DISEASES OF THE NEW-BORN. 449 

the preparation and examining it under the microscope, the dark rhombic crystals of 
hffimin were easily recognized, showing us that we are dealing with a case of hemorrhage 
taking place probably high up in the intestine. Dr. Wentworth's blood examination 
gives the following results : 

BLOOD EXAMINATION 37. (Wentworth.) 

Erythrocytes 6,245,000 

Haemoglobin 125 per cent. 

The blood spread out very thickly and stained poorly, but the polynuclear leucocytes 
appeared greatly in excess of the other forms. 

The cases which are commonly designated as melcena neonatorum should 
be classed under this heading of the hemorrhagic disease of the new-born, 
and are represented by this case (Case 185), in which the blood examination 
was made by Dr. Wentworth. The child died in a few days. 

An interesting case (Case 186) of this disease was seen by Dr. Townsend 
and myself in consultation with Dr. Bush. 

A male infant apparently healthy at birth developed on the third day of its life ecchy- 
moses on its head, groins, and one foot. There was also hemorrhage from the upper part of 
the intestine on the fifth and sixth day, the dejections being tar-colored from altered blood 
which simulated meconium. On the fifth day the child developed a marked paralysis of 
the left side of the face, and to a less degree of the left arm and leg, presumably from a 
meningeal hemorrhage. On the seventh day of the disease the hemorrhage had apparently 
ceased, as the paralysis was beginning to disappear. On the twelfth day the paralysis of 
the left arm and leg had improved : there was, however, still some paralysis on the left side 
of the face, but this did not continue to any great extent, and in the third and fourth weeks 
decided improvement took place in the child's condition, and there were no longer any evi- 
dences of hemorrhage nor any paralysis. 

This infant improved rapidly during its first year, and is now living, healthy and strong. 
It learned to walk and talk rather later than usual, but now at four years of age is in a 
normal condition both mentally and physically. 

I have met with a number of cases in which these hemorrhages oc- 
curred and in which they varied greatly as to extent and persistence. The 
cases in which umbilical hemorrhage was present showed this same ten- 
dency to self-limitation, and could be distinguished from those which are 
classed under haemophilia. In fact, it is probable that most cases of umbil- 
ical hemorrhage are caused by infection and are not especially connected 
with haemophilia. 

I have here to report to you a case (Case 187) of umbilical hemorrhage in a male which 
illustrates what I have just said concerning the desirability of separating the hemorrhages 
taking place in the early days and weeks of infancy from those which occur later and in 
childhood. 

The parents of the infant were well and strong, and were Russian Poles. They had 
another child, eighteen months old, which was healthy. The mother had never had any 
miscarriages, and stated that her parents were healthy, as were also those of the father. 

The labor was a normal one, the child presenting in the first position, and nothing 
abnormal was noticed, except that the placental end of the cord continued to blood quite 
freely notwithstanding the application of two ligatures. On the day following the delivery 
the mother and infant were both doing well ; the latter showed slight signs of icterus, but 

29 



450 PEDIATRICS. 

nursed well, and the former had plenty of good breast-milk. The infant continued to 
thrive, except that there was a slight hemorrhage around the insertion of the cord, which 
fell off on the eighth day. After the separation of the cord a slight hemorrhage from the 
umbilicus continued. On the thirteenth day the hemorrhage increased and became so 
extensive that I was sent for to see the infant. It was then found to be decidedly jaun- 
diced, though not deeply so. It was nursing well, but looked thin and puny. Nothing 
abnormal was found on making a physical examination. Pale watery-looking blood was 
oozing from the umbilicus, and quite a large cloth had been soaked with the blood from 
the umbilicus, giving evidence of a considerable hemorrhage. The umbilicus was plugged 
with small pieces of lint soaked in perchloride of iron, firmly compressed by a bandage, and 
alternate drop doses of fluid extract of ergot and tincture of chloride of iron were ordered 
to be given three times a day. 

On the fifteenth day the hemorrhage had somewhat abated, TDut it was not thought 
advisable to remove the bandage ; the ergot was omitted, on account of nausea and 
vomiting. 

On the sixteenth day the infant was reported to have vomited and cried a great deal, 
and the plugs of lint had been forced out of the umbilicus, leaving a bleeding surface ; the 
umbilicus was then tamponed with Monsel's solution of subsulphate of iron ; the tincture 
of chloride of iron was omitted, as it caused vomiting. The hemorrhage then lessened and 
at times ceased. 

On the seventeenth day the older child pricked the infant's lip with a pin, and on the 
eighteenth day the lip was found to be still bleeding. The point of hemorrhage was 
cauterized with a stick of nitrate of silver. This controlled the hemorrhage for about two 
hours, when it returned and continued. Compression of the lip finally stopped the hemor- 
rhage on the twenty-fourth day. 

On the nineteenth day the hemorrhage had ceased at the umbilicus, and the child con- 
tinued to nurse well. 

On the twenty-ninth day the bandage and lint were removed from the umbilicus, and 
the abdomen was washed. There was no hemorrhage ; the child looked better, and there 
was not so much icterus. 

On the thirtieth day the infant was reported to be perfectly well. It continued to 
thrive from this time, with no recurrence of the hemorrhage. 

On the sixtieth day, although I advised that the operation should not be performed, 
the infant, in accordance with the Jewish custom, was circumcised. I was present at the 
circumcision, to see if the hemorrhage would be easily arrested. The circumcision was per- 
formed without accident, and the hemorrhage was immediately arrested by a weak solution 
of iron. From this time there was no hemorrhage, and the child continued to be strong 
and well. 

This case is an instance of the self-limitation of the hemorrhagic disease of the new- 
born, since, although it was a pronounced case of umbilical and general hemorrhage 
at the beginning of the infant's life, this tendency had ceased by the end of the second 
month, as was evidenced by the ready control of the hemorrhage after the circumcision. 

In another case (Case 188) which came under my notice the hemorrhage took place 
from the umbilicus in the early days of life at the time of the separation of the cord, and 
was completely uncontrolled even by ligatures passed around needles introduced through 
the skin of the abdomen on either side of the umbilicus This case eventually re- 
covered. 

In none of these cases has a tendency to bleeding developed in later life. 

At times we meet with what are apparently very mild cases of this 
disease. I have here the record of a case which occurred in the practice of 
Dr. George Haven, with whom I saw it in consultation. 

The infant (Case 189), a girl, well developed, and weighing 3358 grammes (about 7 
pounds 6 ounces), was born at 12.45 a.m. Nothing abnormal was found on examining it, 



DISEASES OF THE NEW-BORN. 



451 



and it was perfectly quiet until fourteen hours after its birth, when it began to be very restless. 
This restlessness continued, and the temperature, which at birth was 38.6° C. (101.5° F.) in 
the rectum, began to rise, until at the end of twenty-four hours it had reached 39.4° C. 
(103° F.). When it was thirty-six hours old, minute hemorrhagic maculae were noticed, 
first on the back of its right hand and arm and then on the right side of its back. A few 
hours later a number of these maculae also appeared on the right side of the chest, near the 
arm. It nursed vigorously, and did not show any signs of weakness, but its respirations were 
at times quite irregular. From this time no new lesions of the skin appeared, and no 
hemorrhages from any other locality, the maculse gradually fading away in ten days. After 
the first day the temperature fell gradually, and on the fifth day was again normal. Whether 
there was any loss of weight during the first ten days of life was not known, as it was con- 
sidered unwise in the infant's precarious condition to weigh it. 

Here is the temperature chart (Chart 9), which illustrates what I have already told you 
in describing the disease, — namely, the rise of temperature, and in favorable cases the return 
to the normal degree in a few days. 

CHAET 9. 





Dctys ofJ)isectse 






F 


1 


2 


3 


4 


5 


6 


7 


c 




107° 
106° 
105° 
104° 
103° 
102° 
101° 
100° 
99° 

NORML 

TEMP 

98° 

97° 
96° 
95° 


M E 


M E 


IM E 


M E 


M E 


M E 


M E 


4I.6'> 

41. P 

40.5'> 

40.0«> 

39.4° 

38,8° 

38.3° 

37.7° 

37.2° 
37.0° 
36 6° 

36, 1° 

35.5° 

35,0° 






















































































i 














1 


V 














1 




/ 












A- 


— 


V 


v 


^ 


V-- 

































































Hemorrhagic disease of the new-hom. Female, 24 hours old. 

The cord separated on the tenth day without hemorrhage, and subsequently no 
abnormal symptoms arose, and the infant continued to thrive during the whole period 
of its lactation. 



HEMOPHILIA. — In contradistinction to the hemorrliages of infec- 
tious origin which occur in the early weeks of life is that class of hemor- 
rhages which, as I have already said, can be classed under the term 
haemophilia. 

Haemophilia simply means a morbid condition characterized by a ten- 
dency to bleed spontaneously or from any insignificant wound. Individuals 
who are liable to bleed in this way are designated as having a hemorrhagic 
diathesis. The disease is not especially common in the early weeks of life, 
and usually occurs at a later period of development. It begins to be more 
frequent towards the end of the first year, and is apparently well established 



452 PEDIATRICS. 

in the second year and later in childhood. It does not have a self-limited 
course, as is the case with the other form of hemorrhage. It is not infec- 
tious, and is not accompanied by fever. It may be for many years masked, 
and then may arise from some trivial cause, such as the extraction of a tooth. 
It is a dangerous disease, and death is very liable to occur from inability to 
control the hemorrhage. 

There is no treatment which has been found successful in these cases 
beyond the active local employment of styptics and compression. 

TETANUS NEONATORUM. — Although the group of symptoms 
representing the disease usually known as tetanus neonatorum, or trismus 
nascentium, is essentially of a nervous character, yet, as it occurs invari- 
ably in the early weeks of life, I have thought it best to speak of it in this 
connection. 

The whole course of the disease, its self-limitation, and the high tem- 
perature at the time of its invasion, would naturally lead us to classify it 
among the other diseases of infectious origin which I have just described to 
you. The disease usually occurs in infants from the third to the twelfth day 
of life, and is almost always fatal in two or three weeks. 

Etiology. — The cause of the disease is supposed to be the same as that 
of tetanus in the adult ; that is, the bacillus of tetanus. 

Symptoms. — After considerable restlessness and muscular twitching 
lasting for some hours, the infant assumes a very characteristic appearance. 
There is extreme rigidity of the legs and body. This rigidity sometimes 
takes the form of opisthotonos and trismus. The eyes are almost closed, 
but the infant is sleepless. The entire trunk and limbs are so stiff that 
the infant remains in whatever position it is placed in. It is unable to 
nurse, and is found to have a high temperature, occasionally reaching 40° C. 
(104° F.), and a pulse of 150 or 160. At times it will have slight convul- 
sive attacks. 

This disease is epidemic in tropical climates, but as we see it is usually 
of a sporadic nature. It is extremely fatal. When recovery takes place 
the improvement is very gradual, the temperature and pulse decreasing and 
the rigidity of the muscles passing away very slowly, with at times a recur- 
rence of the symptoms. 

Treatment. — The treatment of this disease has thus far been very un- 
satisfactory, although a great number of drugs have been employed, such as 
atropia injected subcutaneously, and such sedatives as bromide of potash 
and hydrate of chloral. 

The form of treatment which appears to me most rational is to place the 
child during the continuation of the tonic spasm in a warm bath and to give 
it .06 gramme (1 grain) of hydrate of chloral every hour until the effects 
of the drug are shown by the lessening of the muscular rigidity and by a 
disposition to sleep. In addition to this treatment, small quantities of milk, 
15 c.c. (about J ounce), should be given to the infant by means of a dropper 
every hour, and to each feeding three drops of brandy or some stimulant 



DISEASES OF THE NEW-BORN. 453 

should be added. Under this treatment a certain number of cases have been 
known to live. 

I have here a case (Case 190) which was first brought to the hospital 
two days ago with the following history : 

A male, said to have been healthy at birth and to have nursed without difficulty during 
the first week of its life. It then refused to nurse, apparently from inability to open its jaws. 
It sometimes cried, but feebly. There were no convulsions, no vomiting, and no rigidity in 
any other part of the body. The temperature was not taken. On physical examination it 
was found that, although the infant could swallow, the jaw could not be opened wider than 
1.2 cm. (J inch). On forcing the finger between the jaws, nothing abnormal was discovered 
in the mouth or pharynx. The respiration was regular, but rather shallow, and there was 
no evidence of injury. Nothing else abnormal was discovered about the infant. 

The infant was given .06 gramme (1 grain) of hydrate of chloral three or four times 
in the twenty-four hours, and to-day shows marked improvement, and, with the exception 
of still being unable to open the jaws widely, nothing else abnormal has been discovered. 
The rectal temperature is to-day normal. 

The infant has probably passed through the active part of the disease in safety, and it 
seems likely that it will recover. 

This, of course, is not a typical case of tetanus neonatorum, but is one of the milder 
forms of trismus. 

SCLEREMA NEONATORUM. — Sclerema neonatorum is a disease 
which occurs in the early days of life, and usually among those who are 
born in the midst of exceedingly poor hygienic surroundings and iu cold 
weather. It is characterized by a hardening of the skin and the subcu- 
taneous cellular tissue and by a great reduction in the temperature. The 
tissues continue to grow cooler and harder until death, which occurs usually 
about the ninth day. It is a rare and exceedingly fatal disease. 

It should not be looked upon as a local disease of the skia, but as some 
obscure constitutional affection of the respiratory and circulatory systems, 
as shown by the shallow respirations and the diminished activity of the 
circulation. 

Symptoms. — Soon after birth, spots of circumscribed hardness appear on 
the skin. These spots soon become diifase, and the disease, starting, as it 
usually does, in the feet or the calves of the legs, passes up the thighs to the 
trunk. It may, however, first appear upon the face and upper extremities, 
though not commonly. The skin has a waxy and glistenuig look, and is 
hard and cold ; the limbs become thick, stiff, and misshapen. The uifant 
soon grows weak and somnolent, and refuses to take its food ; the breathing 
becomes rapid and superficial, the voice is weak and whimpering, and the 
pulse small and retarded. Towards the end of life a discharge of bloody 
serum from the mouth and nose often occurs, and death takes place seem- 
ingly from inanition. 

Treatment. — There is no treatment which has been especially suc- 
cessful in this disease, but the affection should be recognized at once, and 
energetically treated with inunctions of hot oil and by massage and stimu- 
lants. 

A number of cases of this disease have been reported in Europe, and 



454 PEDIATRICS. 

several in this country, notably by Osier. Some investigators think that 
they have found characteristic changes in the skin. The observations of 
Northrup, however, who published the first report of a typical case of this 
kind in America, seem to show that there is no definite lesion of the skin. 
Northrup made a careful study of his case, and has plainly shown by sec- 
tions of the skin compared with normal control specimens that the histology 
of the disease does not reveal any change which can be regarded as charac- 
teristic. Dr. ISTorthrup's case embodied every feature of the typical sclerema 
of the new-born. The infant was a foundling, born in a wretched, damp 
habitation, and was the weaker of twins. On the fifth day of its life the 
feet were found to be swollen, and soon began to give on palpation a feeling 
of hardness like that of a board. This condition soon spread upward to 
the legs, thighs, hips, shoulders, arms, face, and scalp. The w^hole body 
felt as though it were half frozen. The temperature in the rectum was 
under 35° C. (95° F.). The infant died on the ninth day. 

N-<^VUS. — There are two forms of pathological disturbance in connec- 
tion with the blood-vessels of the skin which, appearing at birth, constitute 
a disease called ncevus. Both these forms can appear on the skin of any 
part of the infant, but its occurrence is especially unfortunate when it is 
located on the face. 

The first form is very superficial in its distribution, and is the one which 
is usually called " port-wine mark." This forili can in a number of cases 
be destroyed by the use of electricity. The second form, which is deep in 
its distribution, as a rule needs to be treated by the knife or the Paquelin 
cautery. Cases of the superficial form of nsevus are quite common and 
vary greatly in degree. A frequent locality is between the eyes at the 
bridge of the nose, and another is on one of the eyelids. Often in these 
cases the disturbance disappears of itself after a few weeks or months and 
does not return. In other cases the lesion rernains, often increases, and 
continues, unless treated, through life. In the second form much can be 
done by operative interference. This form also varies greatly in size and 
in the degree of the telangiectasis. In operating on these cases it should 
be remembered that at times the hemorrhage is great, and that the infants 
are liable to die from exhaustion. The following case (Case 191) was seen 
by me with Dr. Lovett : 

An infant four months old was born with a superficial naevus on the forehead. This 
naevus increased in size, and at four months showed a deep discolored protrusion the size of 
a half-dollar on the left side of the forehead. Dr. Lovett removed the growth by incisions 
extending into the sound tissues. There was much hemorrhage at the time of the opera- 
tion, and after the operation great prostration, apparently from loss of blood. The infant 
was treated with stimulants and the application of heat ; it was fed on a carefully arranged 
substitute food for a number of days, and finally recovered. At the end of a year all that 
remained of the original lesion was a very slight scar on the forehead. 



DIVISION IX. 

DISEASES OF THE SKIN. 



In a previous lecture (Lecture XIII., page 320) I referred to the 
importance of inspection as a means to be employed in making a diagnosis 
of diseases in children. The rule that the child should be inspected in 
every part is especially applicable to the class of cases which I am now 
about to describe to you. 

The lesions of the skin in children differ somewhat from those which 
occur in adults, and these variations, both in degree and in kind, often 
make a differential diagnosis more difficult than in adults. Every prac- 
titioner has doubtless been struck by the similarity which at times is seen 
in the cutaneous lesions of the various forms of erythema to those of 
such diseases as syphilis, scarlet fever, and erysipelas. I have seen in 
consultation the delicate pink of an abdominal erysipelas in a young infant 
mistaken so completely for scarlet fever that the precaution of removing the 
carpet in the room had already been taken. In like manner I have known 
a slight grade of the efilorescence of scarlet fever to be mistaken for that 
of erythema neonatorum. I have also seen a harmless papular erythema 
closely simulating and mistaken for one of the papular efflorescences of 
syphilis. 

Another rule, and one of equal importance, is that no single dermal 
lesion, whether it be a macule, a papule, a vesicle, or a pustule, makes it 
justifiable for us to decide that an especial disease is present. We must 
remember that the same cutaneous lesion may appear in almost any disease, 
and that it is the combination of dermal lesions and general symptoms 
which makes up the entire picture of the disease and justifies us in making 
a diagnosis. 

I shall not attempt to speak at length concerning the local diseases 
of the skin. These diseases come ratlier Avithin the province of the der- 
matologist. I wish, however, to show you a few illustrative cases of 
the more common cutaneous affections which you will meet with in your 

455 



456 



PEDIATRICS. 



practice and will be obliged at least to differentiate from the constitutional 
diseases with dermal lesions which you will have to treat. 

The first case (Case 192) that I have to show you is one which represents 
the purest type of a primary disease of the skin. It is caused by an especial 
parasite of the skin, the Acarus scabiei. 

SCABIES. — This child, two and a half years old, is healthy and well developed. 

For the last two weeks it has been very irritable, and its mother has brought it to the 
hospital to inquire about an efflorescence which has appeared on its skin. 

On investigating the lesions we find a number of small papules and a few pustules 
scattered irregularly over the arms and chest, and one or two small pustules on the soles of 

Case 192. 




Female, 2}4 years old, with lesions of the skin caused by the Acarus scabiei. 



the feet. The fingers are not especially affected, but in one or two places at the base of 
the fingers the efflorescence may be plainly seen. In addition to the papules and pustules 
there are numerous lesions of the skin caused by scratching. Here on the delicate skin of 
the abdomen is a minute black line with a vesicle at one end of it. On removing carefully 
with a needle a little of the fluid in this vesicle and placing it under the microscope, you will 
see the parasite, which evidently had its habitat in the vesicle. This organism, which I 
shall not describe more fully, as it is best illustrated in your course on diseases of the skin, 
is called the Acarus scabiei, and is the cause of this special dermal lesion. The black line 
represents the burrow by which it enters and through which it travels as far as the vesicle, 
where it lodges and produces irritation, causing first a minute papule, and then a minute 
vesicle. Finally the vesicle may become pustular. 

In contradistinction to the effects of the Acarus scabiei on the skin of adults we find in 



DISEASES OF THE SKIN. 457 

infants and young children that the parasite may attack the soft skin of the soles of the feet, 
while in the adult we do not find the lesions on the soles, as in walking the skin has become 
toughened in that locality. In adults efflorescences on the soles of the feet and the palms 
of the hands are, as you know, rather unusual unless they are connected with syphilis or 
artificial eczema. 

Infants and young children are usually infected by the Acarus scabiei from sleeping in 
the bed with some adult who has scabies. In this case you see that the child's mother shows 
the lesions of scabies between her fingers. 

Treatment. — In the treatment of this disease it is of course very 
important to treat it in the mother as well as in the child. The clothes 
of the bed, of the mother, and of the infant should first be thoroughly- 
steamed, in order to kill the parasite, and it should be impressed upon the 
mother that the treatment must be carried out very carefully, and that all 
the clothes which have come in contact with the skin must be thoroughly 
cleansed. 

The treatment of scabies in the child should differ somewhat from that 
which is employed when the disease occurs in the adult, because the skin 
of the former is much more sensitive than that of the latter. The severe 
remedies which can properly be used in treating the adult should not be 
employed in the treatment of infants and young children. 

In this case I shall adopt the method which I have been in the habit of 
employing, and which was recommended to me by Dr. Bowen as successfully 
used by him in his practice. 

This treatment consists in an application to the skin of this ointment 
(Prescription 47) : 

Prescription 47. 

Metric. Apothecary. 

Gramma. 
R Balsami Peruviani, I R Balsami Peruviani, 

Petrolati aa 60 1 Petrolati aa ^ ii. 

M. M. 

For an infant as old as this, and for older children, an ointment contain- 
ing some sulphur could be employed without much danger of irritating the 
skin (Prescription 48) : 

Prescription 48. 

Metric. Apothecary. 

Gramma. 



R Sulphuris sublimati 7 

Balsami Peruviani, 

Petrolati aa 30 



R Sulphuris sublimati 311 

Balsami Peruviani, 

Petrolati aa 5i. 



M. M 



In the use of either of these ointments the following technique shoukl 
be employed. The child is to be first thoroughly washed with warm water 
and soap. The skin is then dried, and the ointment is api>liod over the 
whole body, avoiding the head, which is seklom attacked by the parasite. 



458 • PEDIATRICS. 

The face especially might be irritated by the ointment. The ointment is 
allowed to remain on the child during the nighty and in the morning is 
washed off with warm water and soap. The skin is then thoroughly pow- 
dered with the zinc and starch powder which I have already mentioned 
(Prescription 2, page 1-^0). This treatment is continued for three or four 
days, and then, if the disease is not entirely cured, it can be repeated for a 
few days more. 

A certain amount of eczema usually follows the treatment, owing to the 
irritation produced by scratching, which is very difficult to prevent. This 
eczema should be treated by soothing applications. 

PEDICULOSIS. — A parasite whose nidus is on the head appears quite 
frequently in children as well as in adults. It is especially met with among 
the poor and ill cared-for. This parasite, the pediculus ccipitis, causes 
extreme irritation of the skin, which often results in eczema. Although 
the pediculus itself is in the hair, yet by its irritating action on the scalp of 
the child it frequently gives rise by reflex influence to patches of eczema 
grouped about the nose and ears. 

Treatment. — In treating these cases the hair and scalp should first be 
saturated with petroleum. This application is allowed to remain on the 
head for several hoiu-s, and later is thoroughly washed off with soap and 
water. The nits should then be carefully removed by means of a fine comb 
wet with vinegar. It is usually necessary to repeat the treatment for two 
or three days. 

IMPETIGO CONTAGIOSA.— I have here two children (Cases 193, 
194) who have a parasitic disease of the skin called impetigo contagiosa. 
It is a disease which usually occurs in children, but it may be found in 
adults. It sometimes appears as an epidemic, and in these cases, in all 
probability, is caused by the same micro-organism as in the isolated cases. 
It is usually met with among the poorly cared-for, but it may attack the 
healthy as w^ll as the sick and weak. 

The form of the efflorescence is variable. Beginning as small vesicles, 
the lesions soon spread over a larger area, coalesce, usually form pustules, 
and later become rapidly covered with a thick yellowish crust. The lesion 
may occur on any part of the body, but is especially common on the face and 
hands. The itching is very slight in these cases, and there is no constitu- 
tional disturbance caused directly by the parasite. In accordance with the 
idea that it is of parasitic origin, the prognosis is favorable, and the disease 
can usually be cured in a w^eek or ten days. 

These boys live in a damp dwelling. They both have lesions on their skin which cannot 
be explained as those of any of the diseases of which I have previously spoken to you or 
which I am about to show you. 

The first case (Case 193) is nine years old. He has lesions on the arms and on the base 
of the nose. They are characterized by some yellowish crusts. 

The other boy (Case 194) is eleven years old, and was apparently infected by the 
former. He presents lesions of the same character as in the first case on the end of his 
nose and on the corner of his mouth. 



DISEASES OF THE SKIN. 459 

Treatment. — The treatment of impetigo contagiosa is very simple, and 
consists in cleanliness, exposure to sunlight, and the application of an oint- 
ment such as this one (Prescription 49) : 

Prescription 49. 

Metric. Apothecary. 

Gramma. 

R Acidi borici 3 I 75 R Acidi borici 31 ; 

Adipis 30 1 00 Adipis gi. 

M. M. 

FURUNCULOSIS. — Closely connected with irjpetigo contagiosa is 
furunculosis, which is supposed to be caused by the same micro-organisms 
that give rise to impetigo contagiosa, but which aifects a different part of the 
skin, such as the deeper portions of the hair-follicle, in contradistinction to 
the upper layers of the skin, the part affected by impetigo contagiosa. 
These micro-organisms are those which are called the " pus organisms,^' and 
are usually represented by the staphylococcus pyogenes aureus. 

Treatment. — The treatment should be with an anti-parasitical ointment 
or solution preferably containing boracic acid. In many cases in addition to 
this local treatment some form of constitutional treatment should be em- 
ployed, as the children are usually in an abnormal condition. The lesions 
should be bathed every day with this solution (Prescription 50) : 

Prescription 50. 
Metric. Apothecary. 

Gramma. 

R Acidi borici 151 R Acidi borici . ^ss; 

Aq. destil 240 1 Aq. destil ^"^iii- 

M. M. 

After the parts have been thoroughly bathed with this solution an oint- 
ment should be spread on linen compresses and applied to the lesions. This 
ointment should be made in the following way (Prescription 51) : 

Prescription 51. 
Metric. ' Apothecary. 

Gramma. 



R Acidi borici 3 

Petrolati 30 



75 R Acidi borici 51 : 

00 Petrolati gi- 



M. M. 

MOLLUSCUM CONTAGIOSUM.— Another probably parasitic dis- 
ease which is rare, but which is more frequent in children than in adults, is 
molluscum contagiosum. It occurs most commonly on the face, though it 
may be found on other parts of the body. The lesions consist of small, firm 
nodules of a whitish color, with a central depression from which matter of 
a sebaceous consistency may be pressed. The diagnosis is not dithcult for 
one who has once seen the efflorescence, the only condition with which it 
might possibly be confused being verruca, which, however, does not occur 



460 



PEDIATRICS. 



commonly on the face, has no central depression, and does not contain any 
substance which may be squeezed out. 

Treatment. — The treatment of these lesions is to puncture them, 
squeeze out their contents, and dress them with the following anti-parasitic 
ointment (Prescription 52) : 

Prescription 52. 
Metric. Apothecary. 



Gramma. 



R Acidi borici 3 

Adipis 30 

M. 



R Acidi borici ^i; 

Adipis . ^i. 

M. 



TINEA TRICOPITYTINA (Kingworm). — The disease called tiiiea 
tricophytina occurs clinically in tAvo forms. The first form affects the 
scalp, and is called tinea tonsurans. The other form attacks the non-hairy 
portions of the body, and is called tinea circinata. 

This little boy (Case 195) has, as you see, two bald spots on the back of his head. 
The hair over the rest of his head is thick, and there are no appearances of loss of hair 





Case 195. 




\ 










* 






[ 


r i 




I 



Tinea tonsurans. Male, 8 years old. 

anywhere else on his scalp. The areas of scalp attacked by this disease vary in size. In 
this special case, however, the spots are about 2.5 cm. (1 inch) in diameter. As a rule, they 
have a fairly regular circumference. On examining the spots you will see that there are 
little short hairs on their surface, which evidently have broken otf from lack of nutrition. 
On the edges of the spots this is especially noticeable. If you place one of the hairs under 
the microscope, you will find a specific organism which has been determined to be the cause 
of this disease. It is of vegetable origin, and consists of masses of spores composed of 
threads of mycelium, some long and some short, which are divided into numerous segments. 

The disease itself is called tinea tricophytina, and the parasite which 
causes it is called the Tricophyton tonsurans. 

Tinea tricophytina has the peculiarity of not appearing on the scalp 
except in children, but is the same disease that occurs in adults in various 



DISEASES OF THE SKIN. 461 

localities, as on the face in men, destroying parts of the beard. It may 
also occui' on any part of the body both in children and in adults. Its cause 
can usually be traced to the same parasitic affection in some other person 
or some animal. 

Tkeatment. — The treatment of this disease should be active, and it is 
usually necessary to continue it for a long time, especially in cases where the 
parasite has attacked the head. This ointment (Prescription 53) is a good 
one to begin the treatment with : 

Prescription 53. 

Metric. Apothecary. 

Gramma. 

R Acidi salicylici, 

Suiphuris . . . ■. aa 3 

Lanolini 30 



R Acidi salicylici, 

75 Suiphuris aa ;5i ; 

Lanolini ^i. 



M. M. 

It should be applied tv^dce daily, and should be thoroughly rubbed into 
the bald spots, the skin first having been washed with soap and water. 

Where the case proves to be somewhat intractable, still stronger appli- 
cations can be used, and, if necessary, a certain amount of carbolic acid can 
be mixed with the ointment, from one-half to one drachm to the ounce 
of ointment. 

The second form of tinea tricophytina, tinea circinata, may at times 
appear as numerous multiple lesions in different parts of the body, and is 
easily affected by anti-parasitic applications. 

TINEA FAVOSA. — The next case (Case 196) represents a parasitic 
disease called favus. Its favorite seat is the scalp, though it may attack any 
part of the body. It appears in the form of small, bright yellow, cup-shaped 
crusts, which upon their removal leave a permanent but superficial cicatrix. 
These yellow crusts penetrate the hair-follicle and destroy the gro^i:h of the 
hair. When placed under the microscope they are found to consist almost 
entirely of mycelium and spores of the form called Achorion schoenleinii. 
The crusts often become confluent, forming a large thick covering over an 
extensive area. 

Treatment. — The treatment is the application of an ointment to 
soften and remove the crusts, epilation, and anti-parasitic ointments such as 
I have already mentioned (Prescription 53). 

ALOPECIA AREATA.— On comparing the bald spots on this little 
boy's head with these on the head of this little girl (Case 197) you will 
notice certain differences. 

You see on drawing aside her long hair that an irregular surface of the scalp is entirely 
free from hair up to where the long hair begins to grow on its edges. The appearance of 
the skin over this spot is normal. 

The nature of the disease has not yet been determined. It must bo 
differentiated from this case (Case 195) of tinea tricophytina which I have 



462 



PEDIATRICS. 



just shown you, and, as you see, it has an entirely different appearance, the 
,skin looking sound and healthy, while in the case of tinea there are numer- 
ous short hairs, which, as I have already explained to you, are broken off 
through the action of the parasite. 

Alopecia areata is somewhat intractable to treatment and runs a rather 
long course, but, as a rule, in children can be cured. 

Case 197. 




Alopecia areata. Female, 5 years old. 

The diagnosis is made by finding a bald spot on the head having the 
appearance which you see here. The remaining part of the scalp is found 
to be in a healthy condition and well covered with hair. 

Treatment. — The treatment is the continual application of stimulating 
remedies, such as ointments of sulphur and tar (Prescriptions 54, 55). 

Prescription 54. 

Metric. Apothecary. 

Gramma. 

R Sulphuris 3175 R Sulphuris ^i; 

Petrolati 30 1 00 Petrolati ^i. 

M. M. 



Prescription 55. 

Metric. Apothecary. 

Gramma. 

R Olei cadini 3 I 75 R Olei cadini ^ i ; 

Petrolati 30 1 00 Petrolati gi. 

M. M. 

These remedies should be used so as to produce a slight rubefaction, but 
not inflammation. 

PEMPHIGUS NEONATORUM.— In addition to the true pemphigus 
of adults, the epidemic pemphigus infantilis, and the pemphigus which is 



DISEASES OF THE SKIN. 463 

secondary to diseases of a debilitating nature, we at times meet with a form 
of pemphigus which seems to be caused by a parasite of the skin. Blom- 
berg has reported cases of this kind ; one in a girl six days old who had an 
efflorescence of pemphigus beginning on the lower legs and quickly spread- 
ing to the thighs, the abdomen, and the front of the thorax. Later the 
forearm and head were attacked, but only a few^ builje appeared on the 
back. The lesions developed quickly on a previously normal skin, and 
disappeared after a few days, leaving a moist, reddened corium. One of the 
bullse on the head was 1.2 cm. (^ inch) in diameter. On the right foot one 
bulla covered all the toes and the sole of the foot. The sole of the left foot 
was covered by three bullae. Entire recovery took place. No evidence of 
an epidemic w^as found to account for this case. Three servant-girls in the 
family who took care of the child and who washed its clothes were affected 
in from three to six days wdth the same efflorescence on their hands and 
arms. Another child and the mother had a few bullae develop on them. 
Blomberg inoculated himself on the forearm with fluid from the bullae, and 
on the following day he was affected with a similar efflorescence, which 
disappeared in three days. 

This class of cases has not yet been fully accepted by dermatologists, 
and we must remember that on the delicate skin of infants and young 
children impetigo contagiosa may cause the lesion of pemphigus through the 
activity of the parasite and the great vulnerability of the skin. 

PEMPHIGUS. — Pemphigus is a disease of a constitutional character, 
and is represented by large blebs and bullae. It occurs at times in infants 
and children as it does in adults. It is very rare, and I shall not describe 
it in detail. There is a form of pemphigus, however, which I have met 
with in infants and children in which bullae of various sizes appear upon 
the limbs and trunk, and which is not connected with syphilis. It usually 
occurs in poorly-nourished children, and can come not only as a disease of 
itself, but also as one of the sequelae of debilitating diseases, such as pneu- 
monia, rheumatism, and others. Where it is secondary to other diseases it 
represents a condition of malnutrition, and in all probability is not con- 
nected with the real disease pemphigus. In my experience this class of 
cases is not especially serious, but merely represents a greater or less degree 
of lack of vitality of the skin. 

Treatment. — There is no especial local treatment Avhich appears to 
benefit this condition of the skin, but it soon disappears when the general 
nutrition of the child has again become normal. 

This form of pemphigus, in which the efflorescence is secondary to other 
diseases, is not usually seen upon the soles of the feet or the palms of the 
hands, and this is of considerable aid in distinguishing the disease from the 
bullous form of syphilis. 

Where pemphigus occurs as an epidemic among inihnts in toundling 
hospitals it is of a more serious nature, and is accompanied by constitu- 
tional symptoms, represented by fever, sometimes lasting from throe t<^) six 



464 PEDIATRICS. 

weeks. In these cases it is usually acute, but it may become chronic, and 
last, with intervals of recurrence, for many weeks or months. These 
cases are more apt to be fatal than the other forms. The true epidemic 
form of purulent pemphigus, as it has been called, is almost always fatal, and 
in cases where it is not secondary to any other disease has a grave prognosis. 
Many of the reported cases of this epidemic form, as well as of the other 
forms of pemphigus, may really be only manifestations of the staphylococcus 
invasion. 

DERMATITIS EXFOLIATIVA NEONATORUM (Eitter's Disease). 
— In the year 1878 Ritter gave the first complete description of the disease 
dermatitis exfoliativa neonatorum. Previous to this date cases of this affec- 
tion had been reported, but many of them were regarded as some rare or 
unusual manifestation of pemphigus. Ritter studied and reported the cases 
which he saw at the Foundling Asylum in Prague from 1868 to 1878. A 
careful review of Ritter's original observations of these cases has been made 
by Elliot, to whom I am indebted for what I have to tell you concerning 
this rare disease. The majority of cases were in male infants, and the mor- 
tality was found to be 48.82 per cent. 

The disease occurred rarely before the end of the first week, and usually 
appeared between the second and the fifth week, of life. It was found 
to vary greatly in the intensity of its symptoms. In some cases a dry 
scaly condition of the skin preceded the subsequent lesions, which had ap- 
parently lasted after the physiological desquamation of the epidermis had 
taken place. 

Symptoms. — The first symptom noticeable in these cases was a diffuse 
redness, usually over the lower half of the face about the mouth, sometimes, 
however, beginning in some other portion of the body, and at times being 
universal from the beginning. This hypersemia of the skin spread rapidly, 
and in a few days became universal, the extremities, as a rule, being the last 
parts affected. The mucous membrane of the mouth and nose was at times 
affected, and the conjunctivae usually participated in the hypersemia. The 
color of the efflorescence varied from a light to a dark purple-red. As the 
hypersemia extended to new surfaces, those which were first affected began to 
desquamate. This desquamation at times gave no evidence of exudation, 
the epidermis being simply thickened, and the loosened epithelium separating 
easily. At times other lesions appeared, such as milia, and sometimes the 
horny layer of the skin was raised above an intensely reddened base, and 
large, irregularly-shaped bullae filled with fluid were formed. After the 
desquamation had taken place the skin recovered its normal condition, 
sometimes very rapidly, but it remained for some time rough and irritable. 
In the cases where there was no exudation a longer time was necessary for 
the separation and regeneration of the epithelium. 

Usually the disease was found to run its course in from seven to ten 
days. Relapses were sometimes observed ten or twelve days after the 
first attack, but were always mild. 



DISEASES OF TPIE SKIN. 465 

In typical cases the process was unaccompanied by any fever or systemic 
disturbances unless some complication existed. The functions were normal, 
and the weight of the infant remained stationary or was even at times 
increased. The fatal cases resulted either from the intensity of the attack 
or from some intercurrent affection or sequela, such as furunculosis. The 
disease is usually recognized as a local septic infection of the skin, and it 
would seem that it should be distinguished from the pemphigus which 
occurs in the early weeks of life. 

I have myself seen but one case in which it seemed that this diagnosis 
of dermatitis exfoliativa could reasonably be made. 

This case (Case 198), a male infant, at the fourth or fifth day of its life presented 
a marked condition of erythema neonatorum. After a few days this erythema began to 
desquamate slightly, but somewhat later a pronounced dermatitis appeared and ran its course 
for a week. During the course of the disease there were lesions of various kinds represented 
by a few pustules and bullae, but mostly by an intense erythema. The lesions gradually 
grew less intense, a profuse desquamation took place, and the skin then presented a normal 
appearance. During the course of the disease the infant did not show any constitutional 
symptoms, and gained somewhat in weight. The parents were healthy, strong people, with 
good hygienic surroundings. 

I shall now speak of some of the more simple forms of dermal lesions 
which frequently occur in infants. 

ERYTHEMA. — Erythema plays an important part in the diseases of 
infants and young children. Although it is one of the most common and 
readily diagnosticated diseases of the skin which occur in early life, yet at 
times it is quite difficult to differentiate it from other diseases, owing to the 
variety of its forms. It may be divided into two broad classes : (1) the 
congestive form, or erythema simplex, which is caused by traumatism and by 
various drugs, and is also symptomatic of the acute exanthemata ; (2) the 
inflammatory form, erythema multiforme, which may affect any part of the 
body and either small or large surfaces. It has, however, a predilection for 
the backs of the hands and of the feet. Its lesions may be represented by 
maculae, or in the process of its evolution these maculae may develop into 
maculo-papules, vesico-papules, papules, vesicles, and even bullae. The 
lesions vary in size. The color varies from bright red to purplish red, 
and is sometimes very vivid. The delicate texture of the skin of young 
subjects is more likely to show variations in the color and the form of its 
lesions than is the fully developed and stronger skin of the adult. 

Symptoms. — The symptoms of the congestive form are varied, and they 
do not accompany each manifestation of the disease with any especial regu- 
larity. The slightest local irritation, whether from parasites or trauma of 
any kind, changes in temperature, reflex irritation from the close connection 
between the digestive organs and the skin, and many other reflex manifesta- 
tions, may produce the disease. 

In erythema multiforme there may be pains in the joints sinudatiiig 
rheumatism, malaise, slight fever, nausea, coated tongue, loss of a})})otite, and 

30 



466 PEDIATRICS. 

a swollen, tender skin. These more marked symptoms are, however, often 
absent, and the lesions of an erythema multiforme commonly appear on the 
skin of young subjects without any especial general symptoms accompanying 
them. It is better in your nursery practice not to endeavor to classify this 
protean disease under special names which have been handed down from 
time immemorial in the text-books, and which have no particular signifi- 
cance. These names have been used indefinitely by physicians, and the 
same form of lesion is sometimes called by one name and sometimes by 
another. 

Treatment. — The treatment of all forms of erythema is practically 
the same. It consists chiefly in the application of a simple powder (Pre- 
scription 56) of oxide of zinc and starch, and of a lotion consisting of either 
lime water or rose water in which calamine and oxide of zinc are suspended 
(Prescription 57). 

Prescription 56. 

Metric. Apothecary. 

Gramma. 

R Zinci oxidi 75 R Ziiici oxidi ^ii; 

Amyli tritici 60 Amyli tritici ^ ii. 

M. M. 

S. — For external application. 



B 



S. — For external application. 

Erythema Intertrigo. — The form of erythema which is called in- 
tertrigo I have already referred to in my lecture on nursery hygiene 
(Lecture V., page 112, Plate III., A), and I showed you a case (Case 42, 
page 132) of this disease at the time that I was explaining the proper way 
to preserve the infant's skin from irritation. I shall, therefore, not speak 
any more in detail concerning this condition, but shall merely state that it 
should be classified as belonging to the congestive form of erythema. 

In the more severe forms of this disease, where the erythematous condi- 
tion has become eczematous, and where the skin in the folds of the groins, 
of the neck, or of the axillse shows fissures and the moist condition repre- 
sented by eczema madidans,' I have found an application of boracic acid 
powder quite efficacious. 

Erythema Nodosum. — Another form of erythema, called erythema 
nodosum, is a disease which is closely allied to erythema multiforme. The 
general characteristics and symptoms of erythema nodosum can be well 
learned by studying the case of this child who has been brought to my 
clinic for examination. 





Prescription 57. 




Metric. 


Apothecary. 
Gramma. 




Zinci oxidi, 




R Zinci oxidi, 




Calaminae pr^paratae . . 


. . aa 7 


5 Calaminse praeparatae . . . 


. aa^ii; 


Aquse calcis 


... 240 


Aquae calcis 


. . gviii 


M. 




M. 





DISEASES OF THE SKIN. 467 

She is a little girl (Case 199), five years old, and until two days ago was perfectly well. 
At that time she began to have loss of appetite, fever, and malaise, followed by pain in both 
her legs. Following these general symptoms this efflorescence appeared in various places 
on her legs. You will notice it above and below the knee, but mostly over the tibia and 
extending down as far as the ankle. These lesions vary from 1,2 to 2.5 cm. (^ to 1 inch) 
in diameter, and are of a somewhat irregular elliptical outline. They are of an erythematous 
type and have a delicate pink color. The skin over these lesions is hot in comparison with 
the unaffected portions of the skin around them. The lesions are tender on pressure, and 
their tissues are somewhat indurated, so that the feeling is that of a hard, raised swelling. 

The disease is self-limited, but is irregular in its course. It usually disappears in about 
two weeks. Its cause is not known. The treatment is simply palliative. 

URTICARIA (Nettle-Rash, Hives). — The term urticaria has been 
applied to an efflorescence characterized, as a rule, by wheals, which appear 
suddenly and disappear quickly. It is accompanied by intense itching and 
burning, and may show itself on any part of the skin, in lesions either small 
or large in number. 

It is commonly caused by irritation of the gastro-enteric tract. The 
disease may end in two or three days, but usually lasts for some weeks, and 
may become chronic ; it is essentially, however, an acute affection. 

If the lesion has been severe there may be slight desquamation, but this is 
rare. Sometimes there may be only one attack ; again there may be relapses, 
and in some forms and in certain skins it may occur from year to year. 

When seeking for the cause of an outbreak of urticaria you must in- 
vestigate carefully as to whether there has been an error in diet. In chil- 
dren some simple article of food may cause an urticaria to appear, just as 
in some adults the disease occurs from an idiosyncrasy which prohibits 
them from eating oysters, lobsters, strawberries, or certain other articles of 
diet. Again, in some individuals certain drugs, such as chloral, bromide of 
potash, chlorate of potash, and belladonna, may cause the dermal lesions 
of urticaria. The wheals of urticaria frequently occur as a symptom in 
the course of various diseases, such as scabies, or may be caused by the bites 
of insects. 

Treatment. — The treatment should be directed first to the removal 
of the cause of the dermal irritation. When this cause has been removed 
the dermal lesions will, as a rule, disappear, unless still further irritation 
has been produced by scratching the lesion or by its being too severely 
treated by the physician. 

The diet should be milk for a time, and experiments should be made 
with different articles of food to see which one may cause this especial form 
of irritation. The bowels should be carefully regulated. Tlie local appli- 
cations consist in remedies to relieve the itching and burning, in the wear- 
ing of unirritating clothing and soft linen next the skin, and in a powder of 
starch and zinc, made as I have already described to you (Prescription 57), 
frequently applied to the lesions at intervals during the day. Where the 
itching is extreme, anti-pruritic lotions and ointments should be applied, 
such as the following (Prescriptions 58, 59, page 468) : 



468 PEDIATKICS. 



Prescription 58. 
Metric. Apothecary. 



Gramma, 

R Pulv. calaminae 7 

Aq. calcis 240 

Acidi carbolici 1 



5 R Pulv. calaminse ^\\\ 

Aq. calcis .^viii; 

87 Acidi carbolici ^:^ss. 



M. M. 

When this lotion is not sufficient to allay the irritation and where the 
burning is extreme, this ointment (Prescription 59) can be used : 

Prescription 59. 
Metric. Apothecary. 

Gramma. 

R Menthol 

Adipis ■ ... 30 



6 B Menthol gr. x 

Adipis ^i. 



M. M. 

I have here a little boy (Case 200), sixteen months old, who has been brought to the 
hospital for advice concerning these lesions on his skin. The mother gives the following 
account of the case. 

A woman who had been taking care of him, and beside whom he had slept at night, 
was attacked with facial erysipelas of a rather severe type. The mother was exceedingly 
worried at this occurrence, and consulted her physician as to the probability of her infant's 
having contracted erysipelas. She was assured by the physician that it would be unlikely 
for infection to take place under these circumstances. 

This was two days ago, and to-day she says that early this morning the infant was found 
to have considerable fever, to be vomiting, to feel dull, and to seem quite ill. While hold- 
ing the infant in her lap she noticed that there was a red appearance of the skin covering 
its right knee, and another member of the household, who considered that she had a great 
knowledge of diseases in children, announced to the mother that the infant had erysipe- 
las : the mother at once supposed that it had contracted it from the woman who had facial 
er3'^sipelas. 

On examining the skin you will see that the knee and the upper part of the lower leg are 
swollen and of a vivid red color. On touching it we find that it is not painful, but that the 
skin is hot, and that there is considerable swelling of the tissues. The infant's temperature 
is 40° C. (104° F.), its pulse 150, and it looks as though it were suffering from some grave 
constitutional disease. The color of the efflorescence is identical with that which we at times 
see in cases of erysipelas, and this fact, in connection with the constitutional disturbance, 
would make the mother's supposition that her infant had an attack of erysipelas a reason- 
able one. 

I have already impressed upon you the rule that we should examine the entire skin 
before making a diagnosis of any special disease connected with it. I shall, therefore, 
although it is highly probable that this is a case of erysipelas, investigate the case still 
further. 

Now that its clothes are removed you see that there is no other dermal lesion on the 
infant's front, but on looking at its back you will see a number of lesions, some papular, others 
papulo-vesicular, and here, just below the right scapula, you see a wheal. The infant also 
shows evidence of irritation from the way in which it endeavors to scratch. These lesions 
on the back are evidently not those of infantile erysipelas, and on looking again at the 
original source of disturbance you will notice that instead of the diffuse redness so closely 
simulating erysipelas, which you saw a few minutes ago, there is now an efflorescence 
gradually fading away and becoming lighter in color. 

This change in the appearance of the efflorescence, in connection with the very evident 
lesions of urticaria on the infant's back, leads me to defer making a diagnosis until I have 
questioned the mother still further concerning the infant. 

She now tells me that yesterday the infant had been taken care of by a friend, who allowed 



DISEASES OF THE SKIN. 469 

it to eat some unusual articles of food. We can, therefore, account for the vomiting, loss 
of appetite, malaise, and fever by a disturbance of the digestive organs. 

I can now readily make the correct diagnosis, which is very evident, and which would 
have been impossible if we had only seen the efflorescence as it occurred on the knee and at 
the time when we first saw it. It is a typical case of one of the more severe forms of 
urticaria. 

The next case (Case 201) is a little girl, six years old. There is no history of constitu- 
tional disease in either of her parents. The mother states that she has had no miscarriages. 
The child is said to have been a healthy infant, to have had no diseases, and to have been 
well until six months ago. She then began to complain of frontal headache and to be 
slightly feverish at night. Her appetite grew poor, and she lost in strength and weight. 
She has had no cough. She is slightly anasmic and decidedly nervous. She sleeps well, but 
the bowels are constipated. Nothing unusual has been noticed about the urine. She com- 
plains of palpitation and dyspnoea on exertion. There have been no articular or muscular 
pains. A few weeks ago an efflorescence attended with much itching appeared first on her 
legs and then on her back and face. The soles of her feet and the palms of her hands were 
not afiected. The efflorescence consisted of macules, at times wheals, evanescent from day 
to day, and, as you see, irregular in their distribution. At times the lesions have been 
maculo-papules in certain areas, and also papules. 

An examination of the chest shows the lungs to be normal. The cardiac area of dulness 
is normal. There are no continuous cardiac murmurs. There is slight irregularity of the 
cardiac rhythm, and a sharp ring to the cardiac sounds, especially the second pulmonic 
sound. At times also there is a soft evanescent murmur heard over the base of the heart. 

On closer examination of the efflorescence we find on drawing the finger gently over it 
that the pink color disappears, showing that the macules are caused by a congestion of the 
blood-vessels supplying these areas of the skin. We therefore are not dealing with a 
constitutional condition such as purpura, which would have resulted in a rupture of these 
vessels, and which also would have been free from itching and darker in color. 

The mother naturally asks, what is this disease which so disfigures her child's appear- 
ance. What shall we tell her? In the first place, I have inquired about the child's diet, 
and have found that it has not been a nutritious one. What, however, especially struck 
me was that the child has had for the past year a diet consisting largely of tea. We can 
at once, then, account for her general condition on the supposition that she is an inveterate 
little tea-drinker. Her failure in general health, her headache, nervousness, and occasional 
cardiac murmurs, all correspond to the history of tea-poisoning. 

We can now with these facts obtained from the general history of the case diagnosti- 
cate the efflorescence which plays so great a role in the child's case, for it is the rash for 
which the mother has brought her for treatment. The general appearance and description 
of the case permit us to eliminate in our diagnosis the various efflorescences occurring in 
the course of scarlet fever, measles, and varicella. The absence of hemorrhage, as I have 
already stated, precludes purpura. The absence of heat, of pain, of swelling, and of indu- 
ration of the subcutaneous tissues allows us to eliminate erythema nodosum. The eva- 
nescence of the macules and the great irritation enable us to state that we have not a 
syphilitic erythema to deal with, for, as a rule, the macules of syphilis do not itch. The 
appearance and description of the lesions are not those of eczema. In a word, you have 
before you a case of urticaria. 

As to the cause of the urticaria, we must remember that certain drugs, which I have 
already referred to, may produce appearances of this kind on the skin, and the close reflex 
connection between the delicate terminal filaments of the nerves of the stomach and the skin 
may cause a great many disturbances, among which are irritation of the gastric membmne 
and a resulting indigestion. 

In addition to tea and improper food, I find that the child has had quite large doses of 
tincture of chloride of iron given to her. This preparation of iron is a valuable one, and 
was given for the child's anaemia, but in young children it often is of itself a cause of 
gastric irritation such as is represented in this child. It was, therefore, especially as the 
child was constipated, not indicated in her case. 



470 



PEDIATKICS. 



In this class of cases I think that it is best not to give iron at first, hut to allow the 
stomach to recover itself by regulating the diet. I shall treat the child with a milk made 
slightly alkaline with lime water, and with thin soups and bread one day old. I shall 
exclude from her diet tea, pastry, and fried foods of all kinds. Later I shall allow her 
to have a more laxative and less irritating form of iron, such as this (Prescription 44, page 
391). 

Under this treatment, combined with freedom from excitement, baths, and plenty of 
fresh air, I can, from my previous experience with such cases, safely promise the mother 
that the child will improve, become strong and rosy, and soon be relieved from her unfavor- 
able symptoms. 

* 

ECZEMA. — Eczema is a disease of the skin which plays a much greater 
role in infancy and early childhood than in any other period of life. It is 
one of the lesions of the skin which should be placed in the hands of a 
dermatologist. It is so difficult to cure that it must always be looked 
upon as a grave disease. You should, therefore, even in the slight and 
insignificant forms of eczema, be careful not to give a favorable prognosis 
until you have treated the disease for some weeks, for at any time it may 
extend to new areas of the skin. I shall not attempt to give more than a 
very brief description of it. 

It is essentially a form of dermatitis, and we may find the same lesions 
appearing in cases which have been exposed to certain vegetable poisons, 
such as the rhus toxicodendron, to various artificial irritants, or to extremes 
of temperature. 

Before speaking of the general treatment of these cases which we adopt 
in the hospital, I shall show you a few of the cases that have come under my 
care. 

Case 202. 




■ * Eczema capitis. 

Here is an infant (Case 202) in whom the lesions on the skin are confined to the head 
and face. 

These lesions consist of papules, pustules, crusts, some excoriated patches caused by 
scratching, and a thick rather cedematous condition of the skin, especially around the lips, 
nose, and eyes. The hair has been cut off, and you see various lesions on the scalp : in cer- 



DISEASES OF THE SKIN. 



471 



tain parts of the scalp you will notice a reddened moist condition, whicli represents what is 
called eczema ruhrum. This is the same case as the one (Case 48) that I showed you 
at a previous lecture (Lecture V. , page 143) as representing bow-legs. He has returned to 
the hospital with a recurrent eczema of the face and head. 

The treatment of this case is as follows. The crusts and the thickened tissue of the face 
and scalp will first be softened by means of a poultice. After the larger crusts have been 
removed, the mask, which I have already shown you (page 143), will be applied to the face 
and scalp. The inner surface of this mask is thickly spread with this ointment (Prescrip- 
tion 60) : 

Prescription 60. 
Metric. Apothecary. 



Gramma. 



R XJnguenti zinci oxidi, 

Lanolini 

M. 



aa 30 



00 



R Unguenti zinci oxidi, 

Lanolini aa §i 

M. 



Eczema Universale. — The next case (Case 203) which I have to 




Eczema universale. Female, 5 years old. 
I. Before treatment. 



show yon is one that is being treated for an eczema which has attacked 
the face, head, trunk, and extremities of a little girl five years old. 



472 PEDIATRICS. 

You see on examining her naked that almost every form of eczema is represented in 
some part of her skin. Here on the right lower arm and the upper right leg we have a form 
of eczema rubrum ; that is, an intensely reddened and moist surface. On the left upper leg 
are numerous papules, representing the papular form of eczema. On the backs of the hands 
and upper surfaces of the feet are some spots, which represent the macular form of eczema. 
On the trunk, lower legs, upper arms, face, and scalp is a collection of thick crasts, repre- 
senting the form which is called eczema impetiginosum. There is such intense itching con- 
nected with this form of eczema that the child is continually scratching its skin and making 
the disease worse. You must remember this fact, because scratching for a few minutes may 
retard the recovery of an eczema for many weeks, and therefore it is of the utmost impor- 
tance for the success of the treatment of a case of this kind, as well as of any of the milder 
and more local forms of eczema, absolutely to prevent the child from scratching. This can 
in such cases as are here represented be accomplished only by the complete control of the 
child's movements. 

We should first endeavor to allay the itching by means of applications to the whole 
skin , and secondly to bandage the child in such a manner as to make any attempt to scratch 
impossible. I will have this child while you are here in the ward treated by the method by 
which we are accustomed to control and almost invariably cure this disease. 




Eczema universale. 11. Treated by complete rest. 

The child is covered from head to foot with soft cotton cloth compresses thickly spread 
with the ointment which I have just mentioned (Prescription 60). 

It is then placed in this position on its back in bed, and broad straps are drawn across 
its legs, abdomen, chest, and shoulders, thus completely binding its arms to its sides and 
keeping the legs in extension. On either side of the head are placed soft, heavily padded 
sand-bags, which prevent it from moving its head from side to side and thus by rubbing irri- 
tating the eczema of the face. 

It is necessary to have a nurse in continual attendance, in order to soothe the child, and 
by amusing it in various ways induce it to forget what at first may be a rather uncomfortable 
position. This feeling of discomfort usually soon passes away. 

This is not a cruel form of treatment. The irritation is soon relieved when the child is 
kept quiet and prevented from scratching. If necessary, in the early hours of the treatment 
some drugs of a soothing nature may be given to prevent an undue nervous condition of 



DISEASES OF THE SKIN. 



473 



the patient. The nurse should be instructed to be very gentle with it, and continually 
to divert its mind from its skin. Under this treatment in a few days the eczematous con- 
dition of the skin will improve and the itching will diminish. 

(Subsequent history of the case.) You remember the case (Case 203) of 

universal eczema which I showed you at a previous lecture being treated in 

bed. It had improved so much within two weeks that it was allowed to 

be out of bed and dressed, and to have the ointment applied merely on its 

face and head (III.). 

Case 203. 
III. IV. 





Eczema imiversale. HI. Three weeks after beginning of treatment. IV. Four weeks after beginning of 

treatment. 

You see that the skin of the trunk and extremities is almost entirely well. The face 
also is in a much improved condition, and during most of the day she is allowed to have 
the face uncovered and the ointment and bandage applied to her head only (IV.). I hope 
in a few weeks to be able to omit entirely the application of the mask to the face and of 
the bandages to the head. 

The eczema in this class of cases is very apt to recur. 

It is often asked by the mother and nurse whether the eczema of infants 
is contagious. I have seen instances where the nurse who was taking care 
of a case of eczema in an infant had an eczema develop on her hands. This 



474 



PEDIATEICS. 



was apparently caused by the nurse having washed the infant's napkins. 
The hands of the nurse were cured by local treatment, and by using rubber 
gloves in washing the napkins she did not again contract the eczema. Cases 
of this kind give rise to the idea that eczema is contagious, but the proba- 
bility is that they are simply cases of artificial dermatitis caused by irritating 
substances of various kinds, and that there is no especial germ which causes 
eczema. We can, therefore, say that the disease is not contagious, and that 
simple cleanliness and protection of the hands by means of rubber gloves 
are all that is necessary to prevent the disease being contracted. 

I might mention that in this class of cases of universal eczema other 
applications besides that which I have mentioned may often be useful, 
though in my experience and in that of Dr. Bowen there is no one applica- 



Case 204. 





Torticollis from enlarged and tender cervical glands in eczema universale. I. Glands enlarged 
and tender. II. Glands reduced in size and not tender. Female, 6 years old. 

tion which is suitable for all cases, and it is rather the details of applying 
the remedy, keeping the child quiet, and thus allowing the skin to recover 
its vitality, that constitute the important part of the treatment. Where the 
eczema is of a simple erythematous type, with slight itching, an application 



DISEASES OF THE SKIN. 475 

of some powder such as this one (Prescription 57, page 466) is often 
useful, — the child being placed between two sheets and thoroughly dusted 
with the powder, while a nurse is in constant attendance to prevent 
scratching. 

There is one interesting form or rather complication of universal eczema 
a case of which I happen to have here in the wards to-day to show you. 

This little girl (Case 204) came to the hospital to be treated for torticollis. The head 
was drawn to the left side as she now shows you (I.), and she could not straighten it. This 
condition had lasted for many months. 

On examining the child I found that she had the usual universal eczema of a chronic 
type affecting the head, face, and extremities. On examining the neck I found a number 
of enlarged tender glands. These enlarged glands were evidently caused by reflex irritation 
from the eczema, and were the cause of the torticollis. 

She was treated with the ointment which I have just described to you (Prescription 60, 
page 471), and the usual bandage and mask, and to-day, although the eczema is not yet 
cured, the irritation in connection with it has been so much lessened that the glands of the 
neck have gradually subsided and have now disappeared, and the child, as you see, is able 
to hold her head straight (II.). 

I expect the child to receive still further benefit from the treatment, and that she 
will be discharged from the hospital cured. 

In addition to the forms of eczema of which I have already spoken, you 
will meet with many instances of a local eczema which has been produced 
by some irritation either at or near the place affected, or perhaps in some 
entirely different part of the body. This is usually called reflex eczema. 
An example of this form of eczema is where the irritation is on the scalp, 
such as occurs from pediculi, and develops a local reflex eczema on the back 
of the neck. 

PSORIASIS. — This little girl whom I shall now show you has certain 
lesions on her back which it will interest you to examine. These lesions 
are characteristic of the disease called psoriasis. Nothing is known of the 
real cause of psoriasis. So far as we can ascertain, it is not dependent on 
any micro-organism. When the disease is well developed the diagnosis is 
very simple, and its lesions correspond, as a rule, to those which are com- 
monly met with in the adult. It begins with small papules, which almost 
immediately become covered with scales. These scales have a pearly white 
color, and on removing them we find a bleeding surface, showing that they 
are more closely connected ^vdth the corium than is the case in other diseases 
where desquamation takes place, such as dermatitis or scarlet fever. 

The efflorescence of psoriasis is general, and is, as a rule, marked on the 
elbows and knees, for in these places the lesions coalesce and the scales are 
especially thick. 

I have noticed in the psoriasis of children that the type of the dis- 
ease is often so mild that we can scarcely believe we are dealing with the 
same affection that we are accustomed to see in the adult. In some cases 
a few lesions scattered here and there, especially on the back over tlie scap- 
ulae, will be all that represent the disease, and will be easily curtxi, even 



476 PEDIATRICS. 

disappearing of themselves in a few months. Besides affecting the trmik 
and extremities, the efflorescence may occur on the scalp, especially along the 
edge of the hair on the forehead, but the disease is not very common on the 
face. Psoriasis is apt to recur even at intervals of years, so that we cannot 
say that it can be absolutely cured, though at times it may disappear under 
treatment and never return. 

This child (Case 205) has had the disease once previously, and returns to the hospital 
for additional treatment. 

The lesions, as you see, vary in size, and in this case are rather small, being only about 
5 cm. (J inch) in diameter. Many of them are still smaller. You see what an almost 
regular outline they have, and how in the centres of many of them are the characteristic 
small, pearly white scales which at once enable us to diagnosticate the disease. "Where 
these scales are not present, as sometimes occurs in the early stages of the disease, it is much 
more difficult to make the diagnosis. 

The disease is not accompanied by any constitutional symptoms, and, as a rule, there 
are no local symptoms, such as pain and heat. On palpation you find the spots to be 
accompanied by more or less induration of the surrounding tissue. 

Treatment. — The treatment of psoriasis in children should be milder 
in its form than that which you would employ in treating the adult. In 
this case I shall have this ointment (Prescription 61) of chrysarobin applied 
to the lesions in the evening and washed off with soap and water in the 
morning, there being no treatment during the day. 

Prescription 61. 
Metric. Apothecary. 

Gramma. 

R Chrysarobini l 60 R Chrysarobini gr. x ; 

Petrolati 3o|oO Petrolati gi. 

M. M. 

This ointment stains the skin, but not permanently. It should never be 
applied to the face or the scalp, and should be used with great care, as it 
causes on some skins considerable irritation, and at times a severe dermatitis. 
With ordinary caution, however, this need not occur. 

In intractable cases where this milder form of ointment is not efficacious, 
the strength may be increased to 1 or 1.5 grammes (15 or 20 grains) to the 
ounce. 

You should remember that chrysarobin stains the clothes black in- 
delibly, so that old sheets and night apparel should be used while the 
treatment is being carried out. 

In place of this ointment you can use on especially irritable skins, or on 
the face and scalp, this preparation (Prescription 62) of sulphur and tar : 

Prescription 62. 

Metric. Apothecary. 

Gramma. 

R Sulphuris 3 

Olei cadini 1 

Adipis 30 



75 R Sulphuris ^i; 

87 Olei cadini ^ss ; 

00 Adipis gi. 



M. M. 



Case 205. 




Ps^oriasis FeuuiU'. i> vear> old. 



DISEASES OF THE SKIN. 



477 



I have here another case (Case 206) of a boy now seventeen years old, who first came 
under treatment for psoriasis when he was seven years old. 

Under the usual treatment the efflorescence disappeared and the child was apparently 



Case 206. 



F 




t-'v 




6 






Recurrent psoriasis. Male, 17 years old. 

cured. The lesions, however, have reappeared from time to time, and come and go without 
reference to treatment. The lesions which you see on his back are much larger than those 
which you saw on the girl (Case 205). They vary from 2.5 cm. to 5 cm. (1 to 2 inches) in 
diameter, and have a thick, irregular outline. 



PRURIGO. — Prurigo occurs in two forras iu infauts and children, — 
(1) jprurigo mitis infantilis and (2) prurigo fcrox. 

(1) Prurigo Mitis Infantilis. — Prurigo mitis infantilis occurs iu 
infants two or three months old, and may last for some years. 

Symptoms. — It begins with little nodular infiltrations, especially marked 
on the anterior surface of the extremities, and is accompanied by great 



478 PEDIATRICS. 

itching. It may appear on the face. It does not lead to an infiltration of 
the skin or to the formation of pus. 

Treatment. — The treatment consists in remedies to relieve the itching 
and allay the eczema with which it is usually complicated. 

It is closely allied to papular erythema, but is more chronic and has a 
greater tendency to recur. It is very rare in America. 

(2) Prurigo Ferox. — Instead of this mild form a more severe type of 
prurigo occurs at times. This latter form is far more serious in its symp- 
toms and in its prognosis, and may continue through life. The disease, 
which is characterized by the same dermal lesion as that just described, is 
progressive from the beginning ; it usually starts on the legs, and the skin 
becomes thicker as it descends. The efflorescence is accompanied by enlarged 
glands, especially in the inguinal region. 

The disease is rare in America, but is common in Germany. 

Its etiology is very obscure, and it is a most intractable chronic affection. 

Treatment. — The treatment is palliative. 

For the extreme itching caused by the papules an application of this 
ointment (Prescription 63) may be used : 

Prescription 63. 
Metric. Apothecary. 

Gramma. 
R Unguenti diachyli, I R Unguenti diachyli, 

Petrolei aa 30 | 00 Petrolei aa ^i. 

M. M. 

S. — To be applied on flannel three times a day for ten minutes, and to be followed by 
the application of this ointment (Prescription 64) : 



Metric. 

Unguenti diachyli, 
Petrolati 


Pre 

Gran 

. , aa 30 


SCRIPTION 64. 

Apothecary. 
ima. 

R Unguenti diachyli, 
00 Petrolati. . 


M. 




M. 



^i. 



If there is much infiltration, sapo viridis should be applied at night and 
washed off the next morning. It must, however, be used with caution, as 
it is very irritating. 

HERPES ZOSTER.— I have here two cases (Cases 207, 208) to show 
you, — a boy and a girl. They represent the disease called herpes zoster. 
This disease is one which affects both children and adults. I shall, there- 
fore, not dwell especially upon it, but shall merely give you the main 
symptoms and the characteristic appearances of the skin, which will enable 
you to diagnosticate it. 

Symptoms. — The general symptoms of herpes zoster are fever, loss of 
appetite, and pain in some part of the head, trunk, or extremities. The 
pain is always located in the course of certain nerves. In this little girl 
(Case 207) it is in the nerves which supply the skin of the upper part of 



DISEASES OF THE SKIN. 



479 



it IS 



Case 20/ 



the back, the upper part of the axilla, and the upper part of the chest in 
front. 

One of the characteristics of the efflorescence is that, as a rule, 
unilateral. It is extremely rare for the affection to 
be bilateral and to extend around the body. Cases 
of this kind, however, have occurred, and do not seem 
to be any more severe, except that larger surfaces 
are affected than where the affection is unilateral. The 
character of the efflorescence is essentially vesicular, 
and it is to be differentiated from varicella, which might 
be accompanied by the same general symptoms and is 
also essentially a vesicular disease. As I shall presently 
explain to you, the efflorescence of varicella is general, 
is not limited to any special distribution of the nerves, 
nor is it painful, while the efflorescence which we are 
examining here is, as you see, limited to the distribu- 
tion of a special set of nerves, — in this case the bra- 
chial plexus. The vesicles become somewhat pustular, 
and soon crusts are formed. In this case, which has 
lasted three days, there are still a few vesicles to be 
seen, but a large part of the efflorescence is represented 
by crusts. 

The disease runs a definite course of about fourteen 
days, and from the begmning is accompanied by con- 
siderable pain, though according to my observations the pain is not so 
severe in children as in adults, nor is the itching so annoying. 

Herpes zoster, so far as we can determine, is not caused by a micro- 
organism, but is a constitutional disease closely connected with the nerves. 




Herpes zoster of right 
upper chest. Female, 4 
years old. 



The next case (Case 208, page 480), a boy, has the same disease, but it affects a dif- 
ferent set of nerves. 

In this case the efflorescence starts at the sacrum, while in the case of the little girl it 
started over the cervical region. Beginning at the sacrum, it follows the course of the 
nerves, over the left buttock and down the left leg as far as the knee. The various lesions 
are the same as I have just described in the previous case. 

You see, then, the perfect similarity in the character of the lesions and in the distribu- 
tion so far as following a particular set of nerves is concerned. 



Diagnosis. — The diagnosis of this disease is very easily made from 
the general symptoms of pain, fever, and malaise, in combination with 
the characteristic efflorescence, and we at once know with what disease 
we are dealing, for no other affection of' the skin has so definite a distri- 
bution. 

Treatment. — The treatment is simply palliative. AVhat I am accus- 
tomed to do is to reo^ulate carefullv tlie child's diet, as I would in any dis- 
ease with general constitutional symptoms, and to endeavor by the appli- 



480 



PEDIATRICS. 



cation of lotions to allay the pain. The treatment which I shall adopt in 
this case is to powder the lesions thickly with some simple powder (Pre- 
scription 2, page 130). 



Case 208. 




Herpes zoster of lelt leg. Male, 6 years uld. 



PITYRIASIS. — Pityriasis is a term that is now, like the word lichen, 
seldom used without an accompanying adjective. There are two recognized 
forms of the affection. 

(1) Pityriasis Rubra is a rare disease in children, characterized by 
hypersemia and fine scales affecting, as a rule, the whole cutaneous surface. 
It may be attended with great constitutional disturbance and lead to death. 
Its duration is always uncertain. 

(2) Pityriasis Maculata et Circinata, or Pityriasis Rosea, 
affects children as well as adults. It appears in the form of small patches 
of scales scattered over the trunk, legs, and arms. These patches either 
spread peripherally or unite to form larger patches while the centre under- 
goes involution : we thus see a reddish scaling border and a characteristic 
yellowish centre. There may or may not be great pruritus accompanying it. 
In Vienna this affection is still regarded as a form of ringworm, a position 
that cannot, however, be maintained. Its etiology is obscure. It gets 
well spontaneously in from two to ten weeks, and is best treated by mild, 
soothing, and antiparasitic applications. 

VERRUC-<!E (Warts). — Warts are circumscribed outgrowths of the 



DISEASES OF THE SKIN. 481 

papillae of the skin with an accompanying increase in the thickness of the 
epidermic layers. They are common in children, especially on the hands, 
and the old view that they are contagious and auto-inoculable has gained 
many adherents of late. They are of various aspects and shapes, and may 
be treated, as a rule, locally with success, although some are quite obstinate. 
The most efficacious method of treatment is painting each with a solution 
of salicylic acid in flexible collodion (Prescription 65). 

Pkesceiption 65. 

Metric. Apothecary. 

Gramma. 

R Acidi salicylic! 3 

Collodii .30 



75 B Acidi salicylici ^i ; 

00 Collodii |i. 



M. M. 

This is applied with a camel's-hair brush twice a day for three days. 
Then it is soaked off* by prolonged bathing in warm water, with the addition 
of pumice soap if there is no inflammation. This will usually remove a 
portion of the wart, and the process should be repeated as long as any of 
the growth is left. 

The treatment with salicylic acid is not always successful, and recourse 
may then be had to glacial acetic acid, or to some other caustic, careftilly 
applied ; or the growth may be excised. 

LENTIGO (Freckles). — Freckles are small aggregations of pigment 
deposited in the skin, and are commonly seen in children of ten years and 
upward, especially in those of light complexion. They are usually situated 
on the face and hands, but may occur on the covered portions of the body, a 
fact that led Hebra to regard them as not due to the action of the sun. 
There can be no doubt, however, that the sun is the chief agent in their 
production. Their removal is often difficult and requires the use of strong 
irritants, such as corrosive sublimate. It is rarely advisable to attempt 
their removal in young children. 

Melanoderma Lenticularis Progressiva (Kaposi's Disease) is a 
very rare disorder, and is seldom met with in this country. In this affection 
spots of pigment like freckles appear on the uncovered parts of the body 
first, finally extending more or less over the whole cutaneous surface. The 
pigment-spots are the first lesions seen, but later an atrophy of the skin and 
the formation of small angiomata dotted over the surface take place, giving 
the child an extraordinary appearance. The disease is usually found in more 
than one child in the same family, and its etiology is very obscure. Malig- 
nant tumors with a fatal ending usually result from this affection. 

LICHEN. — Many of the affections that were formerly included under 
the head of lichen are now considered by most authorities to belong in otlier 
groups, notably in that of eczema. A diagnosis of lichen is never made by 
American dermatologists, but lichen planus is a well-marked skin disorder 
which retains a place of its own. It rarely occurs in children, but when 

31 



482 PEDIATRICS. 

present it follows about the same course as in adults. It is characterized by 
firm papules of an irregular shape and glistening appearance, of a peculiar 
reddish-blue or violet color, with usually a slight depression in the centre. 
The individual papules may coalesce, so as to form patches of greater or less 
extent, covered with fine scales. It is often accompanied by great itching 
and discomfort. It attacks all parts of the body, showing a predilection, 
however, for the flexor surfaces of the arms and legs. It may last for many 
months, and in the most favorable cases does not disappear for several weeks. 
The general health is not usually aifected, except by the exhaustion that 
may be caused by intense itching. It may be confounded with a papular 
syphilide, which it often closely simulates, and sometimes it may be mistaken 
for an eczema. Arsenic is of value in chronic cases, and antiparasitic lotions 
and ointments, especially those containing tar in some form, give relief as 
external applications. 

ICHTHYOSIS. — The disease ichthyosis as it occurs in infants and young 
children does not differ in its general pathology from that which is seen in 
adults. It may occur in intra-uterine life, and is then designated foetal 
ichthyosis. 

The most thorough work which has been done on the ichthyosis of 
infancy and childhood is that of Ballantyne of Edinburgh, who designates 
that form which has occurred in utero and is fully developed at birth as 
(1) foetal ichthyosis J while the form which begins in the early weeks of 
infancy he speaks of as (2) ichthyosis neonatorum. 

(1) FcETAL Ichthyosis. — The severity of foetal ichthyosis varies 
greatly. The grave form, according to Ballantyne, is developed probably 
about the fourth month of intra-uterine life, and is characterized at the time 
of birth by the existence all over the body of horny epidermic plates sepa- 
rated from one another by fissures and furrows, associated with deformities of 
the mouth, nose, eyes, lips, and limbs, and leading within a few days or even 
hours to the death of the infant. As in most cases infants with this disease 
are born alive, foetal ichthyosis cannot be considered to be a cause of intra- 
uterine death. The disease does not seem to aifect especially the size and 
weight of the infant. As a rule, the viscera at the post-mortem show 
nothing abnormal except an unusual degree of congestion. The microscopic 
examination shows no extension of the keratinizing process on any of the 
mucous membranes. 

The minute anatomy of the disease has been carefully studied by Kyber 
and Carbone, and the most striking feature of the diseased condition is 
found to be an enormous thickening of the epidermal layer. This increase 
in the epidermis is due almost entirely to hypertrophy of the stratum cor- 
neum. The results of still further investigation seem to show that the 
proliferating activity of the cells, instead of being increased, is actually 
diminished. In a case examined by Southworth the rete Malpighii, the 
corium, the sweat glands, the sebaceous glands, and the hair-follicles were 
found to be normal. 



DISEASES OF THE SKIN. 483 

Symptoms. — In the early hours of life infants with this disease usually 
cry loudly and continuously, but sometimes the cry is feeble and often very 
peculiar. The respiration is usually impeded by the blocking of the nostrils 
with epidermic masses. Suction is rendered difficult or altogether impossi- 
ble by the presence of ichthyotic plates around the mouth. They, how- 
ever, are usually able to swallow readily. As a rule, nothing abnormal is 
found in connection with the urine or the faeces. Insomnia is a marked 
symptom. 

These infants have a very repulsive appearance, and there is a cadaveric 
odor arising from the abnormal condition of the skin. This ichthyotic 
condition of the skin is usually universal, but is most evident upon the face. 
The mouth is ordinarily kept open by the contraction of the surrounding 
parts, and from its angles radiate fissures which simulate the rhagades of 
syphilis. The lips are thick and everted, so as to form an irregular entrance 
to the gaping buccal cavity. The chin is receding. The nose can scarcely 
be seen, it is covered so thickly with the epidermic plates around the nostrils. 
There is usually ectropium of both eyelids, but sometimes only of the upper 
one, the orbits seeming to be occupied by fleshy tumors. If, however, we 
separate the swollen eyelids, the normal eyeball is found to lie beneath. 
The external ear seems to have disappeared almost entirely. 

In contradistinction to the opinion formerly held that foetal ichthyosis 
was a general seborrhcea, it is now generally supposed to be connected with 
the disease as it occurs in the adult. 

Peog-nosis. — The prognosis of the disease is almost always imfavor- 
able. 

Treatment. — The treatment should be active and directed towards 
softening the epidermic scales by means of warm oil inunctions. 

Besides the grave form of foetal ichthyosis, there is a much milder form 
of the disease. It develops during intra-uterine life, and shows a contin- 
uous layer of a substance resembling collodion extending over the whole 
body and falling off in small flakes resembling pieces of tissue-paper. These 
general appearances are sometimes accompanied by ectropium and eclabium. 
The disease is not, as a rule, fatal, and often terminates in complete or partial 
cure. There have not been any instances, so far as I know, of an infant's 
being born dead with this form of ichthyosis. 

Treatment. — The treatment of this second form should be by con- 
tinual stimulation of the child's general strength and by great care of the 
skin. 

(2) Ichthyosis Neonatorum. — Ichthyosis in the new-born infant, 
where at birth there was no sign of the disease, may occur. It presents the 
same appearances as the milder form of foetal ichthyosis and the ichthyosis 
of the older child and the adult. 

This is the common form of ichthyosis, which occurs at all ages. It 
usually begins in the early months of life, is essentially chronic, and is very 
intractable to treatment. 



484 PEDIATRICS. 

Treatment. — It should be treated by the administration of a warm 
bath once daily, followed by an inunction with glycerite of starch. 

SCLERODERMA. — Scleroderma is a disease which at times occurs in 
children as it does in adults. It consists of an induration of the skin either 
in bands or in patches, or is diffuse, having a board-like hardness, so that 
the skin cannot be raised by the fingers and feels as though it were tacked 
down. Scleroderma affects the motions of the joints, and when it occurs 
about the chest and throat may interfere with respiration. It appears to 
be a condensation of the fibrous layers of the skin, so that the bundles of 
muscular fibre are packed closely together and are increased in number. It 
is chronic, is not very dangerous, and is best treated by massage and lubri- 
cating applications. 

SCLEREMA NEONATORUM. — Sclerema neonatorum is evidently a 
constitutional disease, and I have therefore already described it in my 
lecture on " Diseases of the New-Born'' (Division VIII., Lecture XX., page 
453). 

CBDEMA NEONATORUM. — (Edema neonatorum is a rare disease, 
which some authorities describe as distinct from sclerema neonatorum, 
the chief difference being that the skin pits on pressure and is not so hard 
as in the latter disease. The general symptoms of the two diseases resemble 
one another very closely. 

ACUTE CIRCUMSCRIBED CEDEMA.— A lesion of the skin which 
has been termed acute circumscribed oedema is represented by the sudden 
appearance of circumscribed swellings of certain parts of the body, varying 
in intensity and size in different localities. It is closely allied to urticaria, 
and was formerly described under the name of giant urticaria. We do not 
know much about either its cause or its pathology. I have sometimes met 
with it in children where it was evidently of reflex origin, depending, prob- 
ably, upon irritation in various parts of the body, such as the mouth, the 
genitals, and the gastro-enteric tract. 

It is not dangerous, may occur at any age, and its treatment is simply 
symptomatic. 

A case illustrating this disease came under my notice not long since. 

A little boy (Case 209), two and one-half years old, had had diarrhoea during the summer, 
and had been left in rather a weak, debilitated condition. He had for some weeks been 
pale, fretful, and constipated. His appetite had been capricious, and he had not cared to 
take any food but milk. When he was nineteen months old an egg had been given to him, 
which he vomited, and later a slight swelling of both eyes had occurred, lasting for a day 
or two. 

When I saw the child the history that was given me was that in the morning he had 
eaten an Qgg. Soon after he became rather dull and cross, but did not vomit. A slight 
swelling of both eyes was then noticed, and later, when I saw him, the right eye was very 
much swollen, so that the conjunctiva was corrugated, and the tissues of the eyelids and of 
the cheek under the eye were so swollen that the eye itself could be examined only with 
the greatest difficulty. Each time that the child had eaten an Qgg this swelling occurred in 
about fifteen minutes. In the course of a few hours the swelling passed off, and did not 
return. An examination of the urine gave the following result : 



DISEASES OF THE SKIN. 485 

ANALYSIS 59. 

Color Normal. 

Keaction Acid. 

Uropliaein Diminished. 

Indoxyl Increased. 

Urea Increased. 

Albumin Absent. 

Sugar Absent. 

Bile pigments Absent. 

Specific gravity 1024. 

Chlorides Normal. 

Earthy phosphates Normal. 

Alkaline phosphates Slightly increased. 

Sediment Slight increase of mucus 

and of epithelial cells. 

Another instance (Case 210) of this kind occurred in a little boy, three years old, in 
whom the peripheral irritation was evidently dependent upon a tight and irritating prepuce. 
In this case sudden cedematous swellings of the fingers and backs of the hands would occur 
at irregular times, lasting for a few hours, and would then entirely disappear. These mani- 
festations continued until the child was circumcised, since which time the symptoms have 
not returned. In this case, also, the urine was found to be normal. 

TUBERCULOSIS OP THE SKIN (Lupus, Scrofuloderma).--The 
next case that I have to show you is one of a class the cause of which for 
many years was unknown. It was designated by various terms, according 
to the different forms which it assumed on the skin. Thus, in one form it 
was called lupus, in another scrofula. We now know that all these forms 
are caused by the same micro-organism, the bacillus of tuberculosis, and that 
this bacillus may find its nidus in the skin as it does in various other organs 
of the body. That is, we may have a local tuberculosis of the skin. 

Case 211. 




Tuberculosis of the skin. Female, 7 years old. 

This little girl (Case 211), seven years old, shows the lesions produced by the tubercle- 
bacillus. 

Tou see these lesions on the arm where they have assumed a circular form, and in the 



486 PEDIATRICS. 

middle part of the forearm is one with the active part of the disease on the periphery. 
Where the disease has destroyed the skin in the middle of the lesion you will notice the 
whitish color of the atrophied skin and the resulting scar. On the right side of the face, 
under the right eye, and around the upper and lower lips are hard masses of indurated 
tissue covered with small nodules, papules, pustules, and crusts. You will also notice that, 
following the general rule of tuberculosis of the skin, the forehead and scalp are not 
affected. 

The child was treated at the Children's Hospital for the disease with the actual cautery. 
Later the tubercular process appeared in the form of nodules in the scar. This disease, 
under all circumstances, is very intractable to treatment, and often causes great deformity. 

This affection does not differ in the child, in its appearances, its course, 
and its general symptoms, from the same disease as met with in the adult. 
I shall, therefore, not speak of it more fully. As a rule, it causes, next to 
syphilis, the greatest destruction of tissue of any known disease of the skin. 
The time of its appearance varies, but it is more common in adults than in 
young children. 

Treatment. — The treatment is the same as is employed when the dis- 
ease occurs in adults. The fundamental object to be attained is the destruc- 
tion of the diseased tissue. Where there is a small isolated area which can be 
easily removed by the knife, this method of treatment should be employed. 
We must remember, however, that by this method it is almost impossible 
to avoid removing the sound tissue with the diseased, and that such good 
results as the avoiding of unsightly scars are not obtained so well by this 
method as by others. Therefore where the tissues are extensively diseased 
and areas are involved where it is desirable to avoid scarring, such as the 
face, a locality which is very frequently attacked by tuberculosis, the actual 
cautery or electro-cautery may preferably be used, and various chemical aids, 
of which the solid stick of nitrate of silver as recommended by the Vienna 
School is a good example, have been found to be very valuable. 



DIVISION X 

SYPHILIS. ERYSIPELAS. THE EXANTHEMATA. 



IvKCTURE :KXII. 

SYPHILIS. 

The specific organism which causes syphilis has not yet been dis- 
covered. The disease as it is manifested in early life appears in two forms, 
— (1) acquired and (2) hereditary. 

The former diifers in no respect from the disease as it occurs in adults, 
and is transmitted by direct infection, usually through one of the mucous 
membranes. Its treatment aod general characteristics are the same as in 
adults, and I shall, therefore, not do more than refer to so broad a subject 
as acquired syphilis. 

HEREDITARY SYPHILIS.— The hereditary form of syphilis, on the 
other hand, plays an important part in the diseases of the early months of 
life, and is an aifection which in all its phases should be thoroughly under- 
stood by those who practise among children. 

By inherited syphilis we mean a congenital disease which has been trans- 
mitted to the child through one of the parents or through both. It makes 
its appearance either in the early months of life (syphilis of the new-born) 
or at a later period towards puberty (retarded syphilis). The stage which is 
met with at birth usually corresponds to an early stage of acquired syphilis, 
while that which is delayed until later childhood or puberty corresponds to 
a later stage. 

The question whether the infant can inherit syphilis from the father 
without the infection of the mother is one which has not yet been deter- 
mined finally. The weight of evidence is in favor of the view that its oc- 
currence in this way is not possible. The probability is that some mild 
and transient form of the disease has been overlooked in cases where the 
mother has been apparently healthy, especially as the mother of a syphilitic 
infant is always immune to infection by her infant. Instances, however, 
occur where it is impossible to say that the mother of an undoubttxlly 
syphilitic infant is also syphilitic. A case of this kind I have here to sh(nv 
you to-day. 

487 



488 PEDIATRICS. 

The father of this infant (Case 212) acknowledges having been treated for a primary 
syphilitic lesion which was followed by pronounced secondary symptoms. The mother 
(Case 213) is, as you see, a healthy, strong woman, who has always been perfectly willing to 
give any information required either as to her own or as to her husband's condition, in order 
to aid in the preservation of her infant's life. She states that she has never had any mis- 
carriages, that she was perfectly well both before and after the birth of this infant, and that 
she has never had an efflorescence on her skin, a sore throat, or any lesions of the mucous 
membranes. She came under my observation when her infant was six weeks old, and has 
since then been seen sufficiently often for me to say that so far as I can determine she has 
had no symptoms that in any way could be attributed to syphilis. She has always had a 
plentiful supply of breast-milk, which was evidently of good quality. 

The severity of the disease determines the type of the efflorescence, and 
is also influenced by the time when the infection of the foetus took place. 
Thus, the later the period of infection the milder will be the form of the 
efflorescence which first appears, while the less severe the general symptoms 
the better will be the prognosis and the greater the amenity of the disease to 
treatment. The reverse of these rules is found where the infection has taken 
place early, and where, as a result, the infant is born dead, or at birth shows 
such advanced stages of the disease as are represented by the more intractable 
forms of efflorescence and severe general symptoms, making the prognosis 
exceedingly grave. 

It is probably possible for a syphilitic foetus to infect its mother in 
utero. This theory of retro-infection, however, has not been universally 
accepted. Fournier believes that there is a class of cases in which the father 
at the time of marriage has no lesion which would necessarily infect the 
mother, where the mother never shows any initial lesion and remains free 
from syphilis so long as she is unimpregnated, and where after impregnation 
she becomes syphilitic and either aborts or gives birth to a syphilitic infant. 
In connection with the subject of retro-infection the question arises whether 
a mother who becomes syphilitic during her pregnancy can infect the foetus 
(post-Gonceptional syphilis). There is no doubt that she may abort from 
her own syphilitic infection, but it has not yet been clearly proved that the 
foetus in these cases is also syphilitic. 

It has been found that Avhere a woman is syphilitic it is exceedingly 
common for her to abort. Miscarriage is more frequent when a woman is 
passing through the early stages of syphilis than later when she has become 
more or less habituated to the disease. The treatment by mercury in these 
cases soon after impregnation, and continued during the pregnancy, is a 
valuable means of averting abortion. You must remember that although 
the aborted foetus of a syphilitic woman is usually macerated, yet such 
a condition of the foetus may be produced by other diseases as well as by 
syphilis. Birch-Hirschfeld has found from an examination of a large 
number of macerated foetuses that seventy per cent, were undoubtedly 
syphilitic. 

Although the tendency to transmit the disease is greatly lessened by 
time, yet the thorough treatment of the parents by mercury is the most 



SYPHILIS. 489 

powerful means of preventing such transmission, and the careful use of this 
drug in proper doses is never contra-indicated. It is, therefore, evident that 
when a syphilitic woman becomes pregnant she should be treated with 
mercury whether she was infected before or after conception. When both 
parents are syphilitic, and when their syphilis is in the early stages, the 
infant is most likely to inherit the disease, and under like conditions the 
disease is apt to be of a severe type. 

Infants entirely free from syphilis, either at birth or later, have been 
known to be born of parents of whom one or both were undoubtedly 
syphilitic. Through the courtesy of my colleagues at the Boston Dispen- 
sary, Dr. Dixwell and Dr. Greenough, I am enabled to show you some 
cases of immunity in children born of syphilitic parents. 

These children (Cases 214 and 215) are two of a family of five, all of whom were 
healthy at birth and none of whom have ever shown any symptoms of syphilis. The father 
was infected with syphilis before marriage, and later infected his wife. They were both 
carefully treated with mercury. The wife has never had any abortions. She has had five 
children and has lost none. Both father and mother have had undoubted secondary and 
tertiary lesions, some of which still exist. 

The father of this next child (Case 216) is a rag-sorter, who had a primary syphilitic 
lesion on his hand twelve years ago. This lesion was followed by secondary symptoms. 
He never had any lesion on the penis. While he was being treated his wife showed symp- 
toms of syphilis and was also treated with mercury. This child has always been healthy, 
and is one of three, none of whom have ever developed any syphilitic lesions. 

Pathology. — The pathological tissue-changes which take place in the 
hereditary form of syphilis are of the same nature as those which occur in 
the acquired form. Diffuse interstitial hyperplasia is much more common 
in the hereditary form than are circumscribed gummy tumors. Changes in 
the bones are very common in hereditary syphilis, and in fact so much so 
that it is usually considered necessary to find these osseous changes in order 
to establish a diagnosis of syphilis in the foetus. 

Liver. — Gubler's description of the alterations which take place in the 
livers of syphilitic infants is as graphic and as reliable as any whicli have 
been since given. The liver is always larger than in the normal con- 
dition. He states that the hepatic tissue is harder and more elastic than 
usual, that it is of a yellow color, and that there are small white granu- 
lations scattered throughout the parenchyma. The hepatic acini under 
normal conditions are in contact, except at the prismatic spaces formed by 
their union, in which spaces the capsule of Glisson forms an envelope to 
the afferent portal vessels of the lobule. It is in these spaces that the 
round lymph-cells form and collect into small lobules representing micro- 
scopic gummata. The gummata of the liver which are found in young 
children with hereditary syphilis resemble those which occur in adults. 

Spleen. — Parrot states that next to the osseous system the spleen is 
the part most often affected by syphilis. It is enlarged, and the degree of 
splenic enlargement is usually characteristic of the severity of the disease. 



490 PEDIATRICS. 

Pancreas. — Birch-Hirschfeld has pointed out the fact that the pancreas 
is frequently found to be affected in hereditary syphilis. He remarks that 
the interstitial changes which he found in the pancreas are analogous to 
those which occur in other organs, especially the liver, and that, while these 
changes are not constant, they come next in frequency to the alterations in 
the spleen. The interference with the function of the pancreas, which must 
occur where it is diseased to any great extent, is probably the cause of the 
gastro-enteric disturbances so common in hereditary syphilis. 

Throat, Upper Air-Passag-es, Thymus Gland, and Heart. — Exten- 
sive lesions are at times found in connection with the pharynx, larynx, 
trachea, and neighboring parts, and also with the thymus gland and with 
the muscles of the heart. 

Lungs. — In cases of hereditary syphilis born before term, and in those 
born at term who live but a few days, the lungs present certain pathological 
conditions represented by nodules or small tumors, usually superficial and 
varying in size. Sometimes an entire lobe may be involved, and the dense, 
altered lung-tissue is colorless gray or white, both on its surface and on its 
section. This condition has been called by Yirchow pneumonia alba, white 
hepatization. 

Kidney and Testicle. — The kidney and testicle may show the lesions 
of syphilis. It is to be noted that the lesions of these organs are amenable 
to treatment. The disease in the testicle is represented by a gradual 
enlargement, and is usually bilateral. 

Osseous System. — The changes in the bones which take place in 
hereditary syphilis are so important, not only on account of their patho- 
logical interest, but also because of their clinical significance, that especial 
attention should be paid to them. 

In this connection it should be remembered that in the latter part of 
intra-uterine life the long bones are cartilaginous and the process of ossifica- 
tion is intra-cartilaginous. As the cartilage changes to bone the cartilage- 
cells increase in number and are closely crowded together. Then comes 
the area of osteoblasts, then the calcareous matter, and deeper down in 
the ossified portions are the blood-vessels running in from the periosteum. 
The epiphyses of the bones of the arm are cartilaginous at birth, and they 
remain separated from the shaft of the bone for some time by a narrow 
cartilaginous layer. It is in this cartilaginous separating layer, called the 
zone of proliferation, represented in this drawing of a normal infant's bone 
(page 10(56, Fig. 148), that certain changes are found in hereditary syphilis. 
This same cartilaginous layer is a marked feature in the changes which 
take place in the bones of cretins and of rhachitic persons. These I shall 
describe later, but, as you see, they are represented in this illustration. 
It is also at this zone of proliferation that the growth in the length of the 
bone takes place, and here syphilitic changes are most often found. This 
lesion is an osteochondritis, and may occur together with lesions of the spleen 
and other parts of the body, or as the only manifestation of the disease. 



SYPHILIS. 491 

Osteochondritis is ordinarily the form of bone-disease in infants. 
Osteoperiostitis belongs almost exclusively to the later forms of hereditary 
syphilis as they appear in well-grown children and in young adults. 

The bones which are affected most commonly are those of the arms and 
of the legs. 

Besides these common osseous lesions a morbid condition of the fingers 
and toes, called dactylitis, occurs quite frequently. In this condition the 
fingers and toes assume a peculiar pyriform shape. 

In addition to these purely syphilitic changes, local thinning of the 
bones of the skull, called craniotabes, occasionally occurs. In this condition 
the bone-substance is absorbed, leaving only the integuments and membranes. 

Symptoms. — In the mild form of the disease the infant may be born 
apparently healthy and may show no indications of its syphilitic inheri- 
tance for some weeks. It is rare, however, for the symptoms to be delayed 
beyond the first three or four months of life. The earliest symptoms of 
hereditary syphilis correspond to the secondary symptoms of acquired 
syphilis. Commonly, unless the infant is born with the effiorescence, 
it is noticed at birth, or within two or three weeks, to have occlusion of 
the nares (snuffles), and, soon after, a hoarse cry and an efflorescence of a 
macular or a papular variety. The efflorescence is general, includes the 
palms of the hands and the soles of the feet, and is especially prominent 
on the forehead. 

The condition of the infant depends considerably on that of the mother. 
The rule is that these infants when born are emaciated, presenting somewhat 
the appearance of these premature infants (Cases 102 and 106, pages 291 
and 303), but I have seen them well developed and apparently in good con- 
dition, as is shown by this infant (Case 218, page 501), which I shall 
presently allow you to examine. The disease, with appropriate treatment 
and good feeding, may in some cases be arrested in this stage, and be cured 
so that it will not return, or it may advance to another group of symptoms, 
which are represented by lesions of the mucous membranes. These lesions 
consist of fissures at the angles of the mouth, mucous patches in the mouth, 
and condylomata of the anus. In addition to these manifestations, pseudo- 
paralysis of one or both limbs of a greater or less degree may occur. All 
these symptoms may arise, run their course, and completely disappear, 
sometimes never to return. Again, they may reappear at various times 
during the indi\dduaPs life, but they are especially liable to return during 
the middle period of childhood and at puberty. 

The Early Manifestations of Hereditary Syphilis. — I have 
already explained to you that we can judge to a great degree as to the 
severity of the disease by the type of the efflorescence, and also by the time 
when it occurs after birth. The mildest and most benign form of syphilitic 
efflorescence is represented by maculde, the next by papulse, and the next by 
pustulde and buUde. Another form of efflorescence simulating psoriasi^^ is 
one of the more severe manifestations of syphilis, as is also that form which 



492 



PEDIATRICS. 



is called rupia, where the efflorescence consists of thick layers of crusts 
arranged one above the other, forming a conical mass, the skin at the base 
being somewhat infiltrated. All of these types of the disease have been 
known to be cured. Finally, you will at times meet with a very dangerous 
form of the disease, which is almost uniformly fatal no matter what the 
treatment may be. This is what is called syphilitic pemphigus, and is 
represented by large and numerous bullae. 

These syphilitic efflorescences, unlike most other lesions of the skin, 
appear commonly on the palms of the hands and the soles of the feet. 

Here is an infant which I showed you at a previous lecture (Lecture XV., 
Case 127, page 367) to illustrate the enlarged spleen which is found com- 
monly in cases of secondary ansemia produced by hereditary syphilis. As 
seen to-day it well illustrates what I have just said concerning the syphilitic 
efflorescence appearing on the soles of the feet. 

Case 127. 




Syphilitic maculae, ulcers, and bullse on the soles of the feet. Male, 2% months old. 



It is a male, two and one-half months old. About one month previous to its birth its 
mother had an efflorescence limited to the head : her hair fell out, and she had a sore throat. 
The infant was apparently healthy at birth and during the filrst six weeks of its life, and had 
no unnatural appearances on its skin. It was then noticed to have an efflorescence of an ery- 
thematous type on the body, face, and arms, including the palms of the hands and the soles 
of the feet. This efflorescence was in the form of maculae of a bluish-red color. On exam- 
ining to-day the soles of the feet, we find, in place of the pronounced maculae which you 
have previously seen, pigmented areas. You will also notice on the under side of the toes 
at their junction with the metatarsal bones a number of bullse, some of which have burst, 
and, the tissue beneath having broken down, ulcerations have been formed. In other parts 
of the soles you will also notice ulcers of various sizes, a few papules, some smaller bullse, 
and the pigmented areas already referred to. 

There is marked occlusion of the nares, and an examination of the nose which has been 
made by Dr. Coolidge shows that the turbinated bones on the left side are swollen and that 
there is some infiltration of the mucous membrane of the naso-pharynx. There is also a 
sero-purulent discharge from the left eye. 

In a case of this kind, provided that we can eliminate the extreme lesions 
of scabies, there can be no doubt that the lesions are those of syphilis. 



SYPHILIS. 493 

In addition to these general symptoms which I have just described, 
there occurs in the hereditary form of syphilis the loss of hair which, as you 
know, is so common in the acquired form of the disease. This alopecia may 
be caused by any of the dermal lesions which occur during the course of the 
disease, but is probably due mostly to the general lack of nutrition in which 
the skin participates with the other organs of the body in syphilis. In 
certain cases the eyebrows and eyelashes are lost, and Barlow believes that 
the former condition is characteristic of the disease, or at least should excite 
a suspicion of its presence. 

Enlargement of the lymph-glands, adenopathy, seems to be less marked 
in hereditary syphilis than in the acquired form. This enlargement may be 
due to reflex irritation from the more severe dermal lesions, but in certain 
cases it is found where no dermal lesion exists. The enlarged glands may 
be in the inguinal, the axillary, or the cervico-maxillary regions. They are 
distinct, movable, multiple, and non-inflammatory. The older the child the 
more likely the glands are to be enlarged. 

According to Post, the nails are involved quite frequently in hereditary 
syphilis, and more frequently than in the syphilis of the adult. The onychia 
occurs in two forms. In the first form a papule or pustule appears on the 
skin at the side of the nail. This ulcerates and extends along the side 
of the nail, at times involving the matrix and causing the loss of the nail. 
The thick and everted edges of the ulcer, its sloughing base and sanious 
discharge, are somewhat characteristic, and are accompanied by a painful 
enlargement of the distal phalanx. 

The effect of hereditary syphilis on dentition is quite marked. The first 
teeth instead of being cut in the sixth or seventh month may not appear 
until the fourteenth or fifteenth month, and sometimes even later. These 
primary teeth are especially liable to decay early. There is nothing suffi- 
ciently characteristic to be of diagnostic value in the appearance of the teeth 
of the first dentition. 

Mr. Hutchinson has observed twenty-three cases of iritis in syphilitic 
infants. The average age for the beginning of the iritis was five and a half 
months. The oldest was sixteen months at the time of the outbreak, the 
youngest six months. Both eyes were affected in eleven cases, and in fifteen 
cases the effusion of lymph was copious. The cornea was affected in a few 
cases. In seven cases the cure was complete, in twelve the pupil was 
partially occluded. Iritis is one of the rarest of the symptoms of heredi- 
tary syphilis, and at times escapes notice on account of the very slight 
symptoms which usually attend it. The diagnosis in these cases is not 
dependent on the iritis alone, but the infants always show other well-marked 
symptoms of syphilis. There is great danger of the disease resulting in 
blindness if it is left untreated, and mercurial treatment is most efficient in 
effecting a cure. 

In regard to the digestive disturbances which arise in these cases of 
hereditary syphilis, it is well to remember that they may depend upon a 



494 PEDIATRICS. 

syphilitic lesion of the liver, spleen, and pancreas, as well as of the stomach 
and intestines. It is, therefore, necessary to treat these disturbances of the 
gastro-enteric tract in a different manner from what is customary where 
a local non-syphilitic cause is supposed to be present. In fact, mercurial 
treatment will produce the best results in these cases. 

An affection called syphilis hsemorrhagica neonatorum is met with at 
times. Bumstead and Taylor have reported two cases of this kind, and 
state that the disease is rare, less than twenty cases having been noted. 
The hemorrhages vary in their extent, and may occur in either the skin 
or the mucous membranes. This class of cases is difficult to differentiate 
from the hemorrhagic disease of the new-born which I have already de- 
scribed. There is no doubt that syphilis has in a number of cases an 
etiological significance in the umbilical hemorrhage which occurs in the 
early days of life. Dr. Uracek has reported a series of hemorrhages in the 
different internal organs apparently depending upon a syphilitic taint in the 
infant. 

The course of syphilis is so influenced by treatment that the symptoms 
must necessarily be irregular. When the disease is untreated, as a rule, all 
the symptoms grow worse. The infant becomes more and more emaciated, 
and either it dies in a few weeks of inanition, or the disease progresses still 
further and serious lesions of the various organs, such as the lung, liver, 
spleen, and kidney, may finally produce a fatal result. The occlusion of 
the nares may increase to such a degree that the breathing of the infant is 
seriously interfered with, and, without any other syphilitic lesion, it may 
die from imperfect oxygenation of the air which enters its lungs. 

This occlusion of the nares may cause great loss of sleep. We must, 
however, understand that, even where this lesion is not of any great extent, 
syphilitic infants suffer from insomnia. This insomnia is usually accom- 
panied by crying, so that it is probable that the restlessness and insomnia 
are due to pain in the bones, as these symptoms are often present where 
there is no digestive disturbance. 

In connection with these syphilitic lesions of the nose, flattening of the 
bridge of the nose is at times a noticeable symptom. 

There is nothing especial to describe concerning the condylomata which 
are found in the anal region and are rare in comparison with the lesions of 
the mouth. They begin as rounded papules, which sometimes coalesce, and 
there is more or less infiltration of their edges and breaking down of their 
centres. 

The syphilitic lesions of the mouth are found so commonly, and are of 
so important a character, that an especial description should be given of 
them. There is no syphilitic lesion of the mouth which is represented 
by a characteristic stomatitis. The mucous membrane in the course of 
hereditary syphilis may at any time be in so sensitive a condition that the 
various forms of stomatitis may be engrafted on it, and we thus may have 
different lesions of the lips, tongue, buccal cavity, and tonsils, which, while 



SYPHILIS. 495 

simply representing the lesions of certain non-syphilitic affections, may, by 
their peculiar grouping in combination with other symptoms, represent the 
hereditary form of syphilis. The lesions most commonly appear around 
the lips and on the mucous membrane lining the cheeks. On the lips 
fissures are exceedingly frequent ; on the upper lip they commonly appear 
on either side of the median lobule, while on the lower lip they are usually 
single and in the median line. The angle of the mouth is often the seat 
of condylomata, and these are frequently covered with crusts and at times 
are deeply ulcerated. A peculiar appearance is in some cases seen at the 
commissures of the mouth, caused by cutaneous ulcerations, which make it 
look larger than normal, and at times produce a number of lines radiating 
from the mouth to the cheeks. Ulcerations may occur on the tongue, the 
lips, and the fauces. Forchheimer has written more fully on these lesions 
of the mouth than any other author, and his observations, now so Avidely 
known, leave little additional to be said on the subject. His description 
of the fissures which occur in syphilitic infants' mouths is very minute. 
He considers that when they are present they leave no doubt as to the diag- 
nosis, since they are infiltrated. The most common place for them to appear 
is at the corner of the mouth. In this place, as a rule, the most striking 
feature of the* fissure is that it is a papule which has been split in or about 
its middle, and that it has an infiltrated edge. The fissures sometimes dis- 
appear in the mucous membrane, sometimes stop before reaching it, and 
sometimes run into it. The fissures may or may not be covered by a crust, 
and, unlike most syphilitic efflorescences, produce more or less pain when the 
mouth is opened. These fissures are called rhagades. They are character- 
ized by their persistency and by their lack of tendency to spontaneous 
healing. Ulcers and plaques muqueuses may be found upon the mucous 
membrane of the lips and cheeks and on the sides and under surface of the 
tongue. They are superficial, but cover more space than the fissures. The 
infiltration is not so well marked, but is present to a greater or less degree. 
The most common lesions which are found on the tongue are these plaques 
muqueuses and ulcers. Both have infiltrated edges, but the plaque in this 
situation rises above the level of the tongue, while the ulcerations are 
considerably depressed. They are both characteristic of syphilis. Their 
locality is determined somewhat by the presence of such irritants as sharp 
teeth pressing against a portion of the tongue. 

The secretion of all these lesions of the mouth and lips is highly 
infectious. 

One of the striking symptoms of this early stage of hereditary syphilis 
results from osteochondritis. According to Post, the form of lesion is 
usually that of a tumor at the junction of the diaphysis and epiphysis at tlie 
distal end of the long bones, though any part of the osseous system may he 
involved. These swellings are difficult to recognize in fat children. The 
tumors rise abruptly from the bones ; they are small and globular, and in 
some cases form a ring at the junction of the shaft and epiphysis ; in others 



496 PEDIATRICS. 

the whole epiphysis is enlarged. At times only a part of the cartilage is 
affected^ and the external swelling is correspondingly circumscribed. The 
lesions appear soon after birth, and their development is completed either 
slowly or rapidly. The termination varies widely. The swelling may be 
absorbed under appropriate treatment, or suppuration may take place and 
the skin break down ; the disease may end in the separation and destruction 
of the epiphysis. The result upon the final growth of the bone varies, of 
course, with the severity of the local disease. When the morbid process is 
arrested before the destruction of either cartilage or epiphysis, there is no 
deformity, but the destruction of cartilage puts an end to growth at that 
point, and a more or less shortened and useless limb results. When the 
disease takes such a course as to separate the epiphysis while the integuments 
remain sound, the limb becomes useless for a time and appears to be para- 
lyzed. The disease was first fully described by Parrot, and is known as 
Parrot's disease, or pseudo-syphilitic infantile paralysis. The joints in im- 
mediate connection with the diseased bones are sometimes involved. There 
may be simply an effusion, but, where the bone is destroyed, serious disor- 
ganization of the joint must follow. The pain and sensitiveness in these 
cases of pseudo-paralysis are probably caused by a low grade of periostitis. 

The bones of the fingers and of the toes, I have already told you, pre- 
sent at times the peculiar lesion which is known as dactylitis syphilitica. 
The phalanx may be enlarged to two or three times its natural size, giving 
the fingers a pyriform shape. One or several fingers or toes may be 
involved, and sometimes the metacarpal bones are diseased. The proximal 
phalanx is more frequently affected than the distal phalanx. In the early 
stages the integument is unchanged ; later, the overlying parts become 
involved and abscesses form. If the case is submitted to early treatment 
the deformity usually subsides, but if untreated the disease may result in 
permanent deformity and uselessness. Dactylitis, however, is not character- 
istic of syphilis alone, as it occurs also as a result of tubercular disease of 
the bone. 

Craniotabes is one of the more uncommon symptoms of hereditary 
syphilis, but, as I have already told you, may in rare cases be found. These 
softened spots, nearly circular in form and about 1.2 cm. (i inch), more or 
less, in diameter, may be recognized by the finger during life. Until lately 
craniotabes was considered to be exclusively a symptom of rhachitis. It is 
found especially in the occiput. It is present in rhachitis where no trace of 
syphilis can be discovered, but it seems to be most common in cases where 
there is a distinct syphilitic taint. Of one hundred cases of craniotabes 
collected by Drs. Barlow and Lees, in forty-seven there was satisfactory 
proof of syphilis. 

Diagnosis. — The diagnosis of hereditary syphilis in its more advanced 
forms, such as I have just described, is not difficult, as no other disease 
represents such serious lesions of the skin with such a combination of 
general symptoms and lesions of the mucous membranes. 



SYPHILIS. 497 

The milder forms of the disease are frequently mistaken for other 
diseases of the skin which simulate the syphilitic lesions but which are of 
a benign character. I have already spoken of these lesions when describing 
such local diseases of the skin as papular erythema, and shall refer to them 
again when speaking of the mild forms of syphilis. 

Occlusion of the nares caused by swelling of the Schneiderian membrane, 
if persisting during the early weeks and months of life without rise of 
temperature, should always make us suspicious of the presence of hereditary 
syphilis, for a syphilitic efflorescence is often so slight and evanescent as 
to be frequently overlooked. 

Marked improvement from the administration of mercury is also usually 
considered of diagnostic value, and, although not by any means conclusive, 
is at least significant. 

Periostitis, especially of the lower end of the humerus or the anterior 
border of the tibia, is met with in children. It should make us suspicious 
that syphilis is causing this condition, especially if there is periostitis of a 
number of bones at once. 

A great deal has been written and much discussion has taken place 
regarding the relationship between syphilis and rhachitis. The two diseases 
are so distinctly separated that it seems scarcely necessary to dwell, except 
very briefly, on the diiferential diagnosis between them. 

Khachitis is so largely dependent in its osseous changes on a profound 
disturbance of nutrition that it can fairly be said to result from any disease 
which from its debilitating nature may interfere with the nutrition of the 
bones. In this way individuals whose nutrition has been seriously affected 
by hereditary syphilis may develop rhachitis. This, in my experience, has 
been a rare occurrence. 

In regard to the actual lesions of the bones present in syphilis and 
rhachitis, there seems to be a concurrence of opinion that the pathological 
conditions are quite different. Thus, according to Cazin and Iscovesco, 
syphilitic bones very rarely present the spongy tissue peculiar to rhachitis, 
and rhachitic bones never show the osteophytes of syphilis. 

Peognosis. — From what I have already told you, the prognosis in any 
case of hereditary syphilis is a serious one. In addition to the results 
which we are likely to have from the syphilis of the parents being early or 
late in regard to the impregnation, and from their having been thoroughly 
treated or not, there are certain facts to be remembered concerning the 
infant itself. 

The prognosis is grave inversely to the number of weeks after birth 
when the disease first shows itself. The milder forms of the efflorescence 
justify us in giving a better prognosis than the more severe ones. In addi- 
tion to these conditions which render the prognosis more favorable are the 
possibility of the infant being fed with good breast-milk or witli a carefully 
prepared substitute food, and good hygienic surroundings. 

The cases in which the spleen is much enlarged are evidently so pro- 



498 PEDIATRICS. 

foundly affected by the secondary anaemia by which the enlargement is 
caused that the prognosis is almost invariably bad, and the degree of 
splenic enlargement may almost be taken as an index of the severity of 
the disease. 

The opinion which we give to the parents should, however, always be 
very guarded, as, even though the disease may for the time apparently be 
entirely cured, it is always liable, as I have already stated, to appear again 
in later childhood and at puberty. When the disease is amenable to treat- 
ment these secondary symptoms almost always disappear by the second 
year, and in quite a large number of cases, where proper treatment has been 
thoroughly carried out, the infant recovers entirely and is as well and strong 
as though it had never had syphilis. In another set of cases, however, 
although the disease is apparently eradicated, in later years it is found to 
have left its marks in disturbances of the different functions and in the 
general lack of vigor of the various tissues. 

Treatment. — The treatment of hereditary syphilis is first to adapt at 
once as nourishing a food as is possible to the infant's digestion. A healthy 
mother with plenty of good breast-milk will, as a rule, provide the best 
food for her infant. 

If the mother's nutrition is reduced by syphilis or by any other chronic 
disease, the infant should be fed on a properl}^ adjusted substitute food, while 
the general hygiene, such as fresh air, sunlight, and warmth, should be care- 
fully regulated. A wet-nurse should not be employed unless she has herself 
had syphilis, in which case the same rules will apply to her nursing as to 
that of the syphilitic mother. A syphilitic infant does not infect its mother 
(Colics' s law). It readily infects a woman who either has never had syphilis 
or who has never given birth to a syphilitic infant. 

It should be remembered that the secretions from a syphilitic infant's 
mouth are very infectious, whether the disease is of the hereditary or of the 
acquired form. If, therefore, the mother is not syphilitic and the infant 
has acquired in any way a syphilitic lesion, the nursing must be discontinued 
and the infant fed on a substitute food. 

The only drug which can be depended upon in the treatment of the early 
lesions of hereditary syphilis is mercury. This drug naturally would be 
employed from our experience with it in acquired syphilis, where, as you 
know, it is more valuable in the early stage of the disease than at any other 
period. In like manner iodide of potash is of little use in the early stages 
of hereditary syphilis, while it becomes useful in the retarded form, which 
corresponds to the later stage of acquired syphilis. 

It is important carefully to adapt the form of mercury which you give 
to the syphilitic infant according to its special idiosyncrasy for the drug, and 
also to regulate the means of its administration according to the necessity of 
having it act quickly, as is indicated in the more severe forms of the disease, 
and according to the sensitiveness of the individual's stomach or skin. Thus, 
mercury may be administered either through the mouth or through the 



SYPHILIS. 499 

skin. In the latter case it may be applied directly in the form of liquid or 
ointment or by means of subcutaneous injections. The last method should 
be used in very urgent cases only, for the tissues and skin of the syphilitic 
infant are especially liable to be irritated to such an extent that sloughing 
may take place, and the tissues under these circumstances are readily de- 
stroyed. When used, it should be in the form of corrosive sublimate. 

The corrosive sublimate should never be given subcutaneously in larger 
doses than 0.0006 gramme (y^Q- grain). Where the mercury is to be applied 
directly to the skin it may be in the form of corrosive sublimate baths, 
0.3 to 0.6 gramme (5 to 10 grains) to each bath once daily, but practically 
it is found better to introduce it into the system by means of an ointment. 
This ointment may be the official mercurial ointment, either in full strength 
or diluted with some simple ointment, and this is very often applied by 
means of inunction, as is the custom in the acquired syphilis of adults. 
After the infant's skin has been thoroughly washed, a small portion of the 
ointment should be applied to its back and rubbed carefully and gently 
into the skin for ten minutes. On the next day the same procedure can 
be carried out on the front of the chest; on the third day in the axil- 
lary regions ; and on the following days respectively on the outer sur- 
faces of the arms and thighs. I have found that the most practical way 
of applying inunctions to these infants is, after having thoroughly washed 
the abdomen, to spread the ointment thickly on a piece of thin soft flannel 
cut so as to reach from the ensiform cartilage to the pubes and to extend 
around the entire abdomen. This ointment is made in the following way 
(Prescription QQ) : 

Prescription 66. 

Metric. Apothecary. 

Gramma. 



R Unguenti oleati hydrargyri, 

Unguenti lanolini aa 60 



R Unguenti oleati hydrargyri, 
00 Unguenti lanolini ...... aa ^ii. 



M. M. 

The band should be allowed to remain in place for forty-eight hours. 
It should then be removed, and, after the skin has been thoroughly washed 
with warm water and soap and dried with a soft toAvel, the flannel should 
again be spread with the ointment and reapplied. 

In giving mercury by the mouth I am in the habit of using the official 
hydrargyrum cum creta. I usually begin with 0.06 gramme (1 grain) of 
the drug, administered three times in the twenty-four hours. Within a few 
days I increase the dose to four times in the twenty-four hours, and if no 
unfavorable symptoms appear I again raise the dose to 0.12 gramme (2 
grains) three or four times in the twenty-four hours. 

The unfavorable symptoms which I have just referred to as possibly 
being caused by the drug are represented by diarrhcea. We must remember 
that the infants whom Ave are treating for hereditary sy})hilis are so young 
that the salivary secretion has been very slightly developed, and that there- 



500 PEDIATRICS. 

fore we naturally do not salivate an infant of this age so readily as we 
would a child or an adult. We must not^ however^ think that we can be 
guided as to the amount of mercury we are introducing into the infant's 
stomach by salivation, which is usually relied upon to indicate the physio- 
logical action of mercury. I have found it a safe rule to continue with 
the mercury until diarrhoea is caused, when the drug can be reduced in 
quantity, or even be omitted for a few days. When the intestine has 
become less sensitive we can again, begin with a smaller dose, and one 
which by experiment has been shown not to cause diarrhoea in the especial 
infant. 

Other forms of mercury, such as calomel in doses of 0.006 gramme {^-^ 
grain) three or four times daily, may be given by the mouth in these cases. 

These various forms of mercury should be tried where for any reason 
one of them is found not to suit the case. 

For the treatment of the fissures which occur around the lips and the 
lesions of the mouth, as well as those which occur at the anal orifice, I am 
in the habit of using a simple powder of calomel, which is dusted on the 
part affected. The mouth should be carefully cleansed several times during 
the day and a wash of chlorate of potash used at least twice a day. In 
some cases, though rarely, nitrate of silver is needed as an application to the 
ulcers when they are intractable. Where there are crusts around the lips 
and in the neighborhood of the fissures, or where anal condylomata are 
present, the ointment (Prescription 66) which I have just shown you is of 
much benefit. The crusts should be carefully removed from the nose and 
this same ointment gently applied to the lesions. The application of this 
ointment to the abdomen is at times followed by an eczematous irritation 
of the skin of the abdomen, as has happened in this case (Case 127, page 
367). Under these circumstances any simple ointment should be applied in 
place of the mercurial for a few days until the skin has recovered, and the 
ointment can then be further diluted with lanoline or some simple ointment 
and reapplied, thus finally adjusting the strength of the mercurial to the 
vulnerability of the infant's skin. 

In addition to the mercurial treatment, tonics in some form, especially 
iron, are at times required. It is usually in the later stages of the disease 
that they are indicated, and in cases where the persistence of the splenic 
enlargement shows the presence of profound secondary anaemia. 

After all the symptoms of syphilis have disappeared and the infant is 
entirely well, the mercurial treatment should be continued for some months, 
and also later during the first three or four years of its life, at intervals 
of three or four months, even where there is no return of the syphilitic 
symptoms. It should likewise be given at intervals during the period of 
the second dentition, and again at puberty. This treatment is especially 
important whether the infant appears to be in good health or not, as it 
tends to prevent a recurrence of the disease, and you should understand 
that a recurrence often proves very intractable to treatment. 



SYPHILIS. 



501 



I have some infants here to-day who illustrate the different phases of 
early hereditary syphilis and the different conditions which you are liable to 
meet with in this disease. 



This first infant (Case 217) is three weeks old. Its naother looks well and strong, denies 
having had any miscarriages or disease of any kind, and asserts that the father is also 
healthy. Both of these statements are probably untrue, as you will presently see ; but we 
have an excellent opportunity for making a diagnosis simply by inspection and by a 
physical examination. 

At birth the infant was puny and atrophic. It soon began to have occlusion of the 
nares. When one week old, an efflorescence of papules appeared on its arms, legs, and feet, 
with pustules on the palms of the hands and the soles of the feet. It does not vomit. The 
faecal movements, as you see on the napkins (Plate III., 4, facing page 112), are of a good 
color and fairly well digested. The heart and lungs are normal. The splenic area of dul- 
ness is slightly increased, but the spleen cannot be felt. You see that there are marked 
fissures at the angles of the mouth, a muco-purulent discharge from the nose, and crusts 
forming on the eyebrows. The mouth and throat show nothing beyond a pronounced ery- 
thema. There are papules and pustules on the body, and a squamous as well as a pustular 
efflorescence on the palms of the hands and the soles of the feet. There are maculae on the 
buttocks. The anus shows nothing abnormal. The temperature is normal. The infant 
looks fairly well nourished. 

There can be no question about the diagnosis in a case like this, and the statements of 
the mother regarding herself and her husband can be entirely ignored, for by simple inspec- 
tion we see at once that we have a case of hereditary syphilis to deal with. 

Before referring to the treatment of this case, I shall ask you to examine 
another infant. 

Case 218. 




Hereditary syphilis, Male, 6 months old. Fed on good breast-milk by a healthy mother. 

This infant (Case 218) is six months old. The mother, a healthy-looking woman with 
plenty of breast-milk, nurses the infant. She has had one miscarriage, in the third month, 
and this is her first child. The father denies having had any venereal disease. 



602 PEDIATRICS. 

At birtli the infant was rather atrophied and had a general papular efflorescence all 
over it, and later a squamous efflorescence on the palms of the hands and the soles of the 
feet. It always had marked occlusion of the nares (snuffles). 

The infant was immediately placed under treatment, and now looks well nourished. 

It is also a case of hereditary syphilis, and shows the beneficial result of good breast- 
milk and mercury, for you see that it is very large for its age and is fat and strong-looking. 
It has, however, certain lesions of the bones which are the result of the syphilitic 
manifestations which it presented at birth. One of these lesions is represented in the 
marked prominences which you see on either side of the frontal bone, with a somewhat 
depressed sulcus between them. 

On examining the infant's hands you will notice a still more characteristic lesion of 
the bone. You see that the first phalanx of the left little finger and that of the left third 
finger are swollen and somewhat reddened, and that the tissues have a tendency to break 
down. This condition is called syphilitic dactylitis. It is not, however, characteristic of 
syphilis alone, for cases of tuberculosis of the bone often simulate this condition, and in fact 
so nearly approach it in appearance that the two diseases cannot be distinguished by simple 
inspection. 

To show you the close resemblance between syphilitic dactylitis and tubercular dac- 
tylitis, I have here an infant (Case 219) on whose hand the same general characteristics will 
be found. In this case the third finger of the left hand is afifected. 

Case 219. 




Tubercular dactylitis. 

In connection with the first of these cases (Case 217) I have stated that while the 
syphilitic infant is described essentially as atrophic, this is, as a rule, the case only when it 
is deprived of good breast-milk or of a properly proportioned substitute food, the atrophy 
being usually a fault in diet, provided that the intra-uterine nutrition has been good. You 
see that neither of these cases is suffering from malnutrition. ■ They are being nursed by 
strong mothers, who are giving them a plentiful supply of milk. The second case (Case 
218) is rapidly recovering, and will soon need only to be seen and treated at intervals. 
In fact, it illustrates remarkably well how healthy an infant may look who is but just 
recovering from the more severe symptoms of infantile syphilis. In the first case (Case 
217) the prognosis is not quite so good, as, although the infant has been under treatment for 
two weeks, the lesions are marked and numerous. What inclines me, however, to look 
upon the case favorably is the improvement which has occurred in the mother's milk, and 
which will naturally find its counterpart in the infant's nutrition. The insomnia and rest- 
lessness which were present in this case have also greatly lessened, showing that the infant 
is improving. 

An interesting and important point to be noticed in this case was that when the mother 
first noticed the efflorescence and brought the child to me she was so much frightened that 
her milk had considerably lessened in quantity, and she was sure that she would lose her 



SYPHILIS. 503 

milk entirely and that her infant would die. Judging that the milk was affected hv the 
mental condition of the mother, I at once caused a marked revulsion in this condition by 
stating decidedly that her milk would soon become plentiful, and that in the mean time she 
could give her infant in addition to her milk about an ounce of the following mixture 
(Prescription 67) : 

Prescription 67. 

Fat 2.00 

Sugar 6.00 

Proteids 1.00 

This substitute food suited the infant's digestion so well that the mother soon ceased to 
believe that it would die, and the desired mental revulsion was so effective that in twenty- 
four hours the infant was receiving its natural supply of breast-milk and the substitute 
food was omitted. 

Syphilis is so prolific a source of miscarriage that a historv^ of mis- 
carriage in the mother justifies us in looking with suspicion on a doubtful 
lesion of the skin in her infant. A woman may have a number of mis- 
carriages caused by syphilis, and may then, if she has been treated with 
mercury, give birth to a living syphilitic infant, or to one that is healthy. 
These facts are important for us to remember when we are considering the 
prognosis in a case of hereditary s}^liilis. For instance, the mothers of 
both of these infants deny having had any disease, and the mother of the 
first case (Case 217) says she has had no miscarriages, while the mother of 
the second case (Case 218) acknowledges that she has had a miscarriage. 
We may take it for granted from the healthy appearance of these mothers 
that they have been treated. This opinion, of course, is merely provisional, 
and does not deal with the additional argument which might be brought up, 
that both infants were infected by the fathers through healthy mothers. 
These two infants have both had the same treatment, and that treatment has 
been essentially good food and mercury in the form of oleate of mercury 
ointment diluted one-half with rose-water ointment and applied on a flannel 
to the abdomen. In addition to this external treatment, hydi'arg\Tum cum 
creta in doses varying from 0.12 to 0.24 gramme (2 to 4 grains) three or 
four times a day has been given. 

The next infant that I shall show you illustrates the trouble that may 
arise from the physician in general practice not thoroughly imderstanding 
the varied forms in which syphilis may manifest itself in infancy. 

This infant (Case 220), a male, four months old, was brought to my clinic three weeks 
ago with syphilis of a rather aggravated type, and among other lesions this condyloma, the 
remains of which you now see at the anal orifice. 

It had a general papular efilorescence on the face, body, and limbs, including the palms 
of the hands and the soles of the feet. The left arm hung helpless by its side. You see that 
it can now move it a little. The left leg was also somewhat affected. On examining the 
arm I found that there was a small, hard, painful, circumscribed swelling at the lower end 
of the humerus. 'No crepitation was detected. The infant was treated with mercury-, and 
a carefully proportioned substitute food was given to it. The mother was cautioned to be 
very gentle when she moved the arm, and to come frequently to the clinic for observation. 

She did not bring the infant again for two weeks, but when she did she was very indig- 



504 PEDIATRICS. 

nant, because she thought her infant had not been properly treated at the previous visit. 
She said that she had been to a surgeon, who had told her that the infant had a broken arm, 
and that the hard swelling was the resulting callus. The mercury was therefore omitted^ 
and a splint applied. It is needless to say that the arm and the infant grew rapidly worse^ 
the left arm also becoming helpless. 

The true nature of the disease was then explained to the woman, the splint was re- 
moved, and a vigorous course of mercurial treatment was carried out with the infant ; and 
to-day you see the rapid improvement which is taking place. 

Here again we had to deal with one of the osseous lesions of syphilis, an osteo- 
chondritis accompanied by periostitis, which caused so much pain on movement as to disable 
the limbs and simulate both paralysis and fracture. 

The next case (Case 221, Plate VI.) is of remarkable interest, owing to the form and 
appearance of the efflorescence, which, though unusual, is so characteristic that it could 
represent no other disease than syphilis. 

The infant is six weeks old. The mother states that she has been married about three 
years, has had two children, and has had no miscarriages. She says that the father is well 
and strong, and that neither of them have had any efflorescence on their skin. 

The older infant is fourteen months old, and is healthy. 

The younger infant is being nursed by its mother. At birth it was apparently healthy 
and well nourished. Its skin was clear, its body fat, and there was no occlusion of the nares. 
This condition continued until it was eight days old. It then began to have occlusion of 
the nares (snuffles), a slightly hoarse voice, and an efflorescence on its back. To-day you see 
that it has an efflorescence on various parts of the body and limbs. This efflorescence con- 
sists mostly of maculse, many of which are circumscribed by healthy skin. They vary in 
size from 0.6 to 1.25 cm. (^ to J inch). 

The lesions can be studied well by examining the right leg and foot, where their appear- 
ances are most clearly depicted. In order to see the exact color and distribution of these 
lesions, which at present are much obscured by dirt, I shall first have the leg and foot 
thoroughly washed with soap and water. This can be done without removing their charac- 
teristic appearances, since they are but slightly squamous, and, being mostly macular, can 
best be studied when the skin has been washed clean. 

In addition to the maculae, which you see varjdng from a delicate pink to a yellowish- 
white color, is a pustule on the outer side of the leg just below the knee. On the inner edge 
and almost on the back of the foot are the remains of a bleb which has broken down and has 
been emptied of its contents. There is also on the inner side of the foot, nearer to the heel, 
a small ulcer. All the other lesions are macule, and you see how distinct are these red 
maculae on the sole of the foot. The entire skin of the heel is reddened and has a shining 
appearance. The erythematous lesions in places on the leg are surrounded by normal skin, 
presenting a mottled appearance, and there are white spots on the skin. These latter, 
however, are caused merely by the peculiar distribution of the syphilitic maculae. 

In addition to these lesions on the leg there are a few ulcers on the buttocks, and in 
addition to the maculae on the soles of the feet there are some on the palms of the hands. A 
few scales showing a squamous condition can be seen on the left leg, but this lesion is not a 
prominent one. 

The eyes are not affected. There are a few fissures about the mouth, but no lesions of 
the buccal mucous membrane, and there are no gummata around the anus. 

The treatment of this case will be by inunction with the oleate of mercury ointment, 
which I have already described (Prescription 66, page 499), and by the administration of 
hydrargyrum cum creta. 

The Later Manifestations of Hereditary Syphilis. — I have 
already told you, in speaking of the manifestations of hereditary syphilis 
which appear at birth, that these symptoms usually develop in the first three 
or four months of the infant's life. In certain cases of syphilis which are 
without doubt of the hereditary form, either no symptoms whatever are 



"'^ 



^# 



PLATE VI, 



jf^f*. 




Erysipelas 



^/ 



"% 



I 



Varicel la • 



Syph His 



CoRyriglill894b/J.B.Lippi(>cott Compan 



SYPHILIS. 505 

noticed in the early years of life, or they are so slight, or so lacking in the 
characteristics of syphilis, that it is sometimes impossible to recognize them 
as syphilitic lesions. The lesions of this late hereditary form correspond to 
the tertiary lesions of the acquired form. They appear in different periods 
of childhood or at puberty. These periods correspond to what I have 
already stated to be the time when a fresh outbreak of an attack of syphilis 
which has occurred in the early months of life is apt to take place. This 
is significant as leading us to suspect that the early symptoms of the disease 
have been overlooked rather than to believe that they did not occiu-. 

The lesions of the bones hold a prominent place in these later manifesta- 
tions of hereditary syphilis. These lesions may be in the form of a peri- 
ostitis, or an actual necrosis of the bone may take place either in connection 
with a dactylitis or with a simple lesion of the osseous tissue in any of the 
bones. 

As these later forms of hereditary syphilis merely represent the same 
conditions as are met with in tertiary acquii-ed syphilis, we should expect 
the most varied lesions. In this late form of hereditary syphilis the bones 
of the nose are frequently involved, and a flattening of the bridge of the 
nose is not uncommon. The cranial bones show certain alterations which 
at times are quite characteristic. The frontal bone may present a promi- 
nence on either side, which, with a depression more or less deep between the 
prominences, causes such a peculiar conformation of the head as to be almost 
characteristic of syphilis. This is well represented in the case (Case 225, 
page 510) which I shall presently show you. In addition to these frontal 
prominences, at times there is a prominence of the centre of the frontal 
bone, which, with the apparent flattening on either side, causes a peculiar 
shape simidating the keel of a ship. Sometimes protuberances similar to 
those which I have described of the frontal bone may appear on the parietal 
bones. When they are bilateral the sagittal suture appears as a depressed 
sulcus between them, and this deformity of the skull, from its resemblance 
to the shape of the nates, has been designated by Parrot as the natiform 
skuJl. 

These tuberosities which I have just described as appearing on the 
skull may also appear upon the long bones, either m the diaphysis or in 
the epiphysis. When the tibia is affected there is often so marked an in- 
crease in parts of the shaft of the bone, especially its middle third, that, 
as the enlargement is chiefly in the anterior portion, the SAvelling when 
prominent gives an appearance of curvature to the bone. This is, however, 
only a seemiug curvature, as the posterior portion of the bone is not aflected. 

An interference with the growth of children who are affected by these 
various osseous lesions of syphilis is not uncommon. There is frequently a 
lack of development, which shows itself usually in a failure of the individual 
to attain the ordinary height. The mental development is retarded, the 
children often appearing to be a number of years younger than they really 
are. This condition Fournier has designated as hijantilisin. 



506 PEDIATRICS. 

The first set of teeth in infants with hereditary syphilis have nothing 
characteristic about them ; they show a lack of nutrition, a condition which 
may arise from many other morbid processes. 

The second set of teeth, however, present certain characteristics. These 
characteristics are shown especially in the two middle upper incisors, in which 
the cutting edge of the tooth is worn away, leaving a convex surface with 
the convexity upward. The teeth are also apt to be somewhat far apart, 
and, as the child grows older, to assume a peg shape. The especial charac- 
teristics of syphilitic teeth were first described by Hutchinson. This peculiar 
shape of the teeth is not always present in syphilis, but when it appears it is 
certainly very suggestive of the disease. As was pointed out by Coleman, 
the dentist who examined Hutchinson's cases, in nearly every one of them 
there was a deficiency in the superior alveolar arch at the anterior portion, 
so great in some cases that when the jaws were closed the upper and the 
lower incisors did not come together. 

I have already described the onychia which occurs as one of the earlier 
manifestations of hereditary syphilis. In the late form of syphilis another 
form of onychia is met with, characterized, according to Post, by a swelling 
at the base or the side of the nail, which becomes thickened, fissured, and 
brittle, with more or less deformity of the phalanx. 

In the late form of syphilis a peculiar inflammation of the cornea at 
times appears. It usually begins with a cloudiness of the substance of the 
cornea, with ciliary congestion. The entire cornea in this way becomes 
clouded. The affection is not accompanied usually by pain, and does not 
show any special congestion of the conjunctivae. Hutchinson says that 
it is always symmetrical, althougli at first it is apt to begin with one eye 
and later to attack the other. The interval between the two attacks may 
extend over several years. This disease is called interstitial keratitis, and 
may for a few weeks almost entirely abolish sight. It usually disappears 
under treatment without leaving any trace behind it. On the other hand, 
opacities are sometimes left and interfere with vision. The total duration 
of the disease varies from six to eighteen months. Interstitial keratitis, 
according to Post, occurs most frequently in female subjects, and is most 
common between the ages of ten and fifteen, although it may occur much 
earlier, and, according to Fournier, may even be met with at birth. 

Complications may arise in the shape of iritis, choroiditis, and retinitis. 

Disturbances of hearing may occur from a number of causes, especially 
as secondary to diseases of the pharynx. An especial form of deafness, 
however, without any special lesions to explain it, occurs in the syphilis 
of childhood, is usually intractable to treatment, and persists into later 
life. Extensive ulcerations produced by syphilis may occur in the nose and 
pharynx at any time during childhood. 

Treatment. — The treatment of the lesions which usually occur in the 
retarded form of syphilis is essentially with iodide of potash, either alone 
or in combination with some mercurial. The iodide of potash should be 



SYPHILIS. 



507 



given at first in doses of 0.12 or 0.18 gramme (2 or 3 grains), and this dose 
should be gradually increased to 0.36 or 0.6 gramme (6 or 10 grains), or 
even more, as children often tolerate this drug remarkably well, and large 
doses are usually indicated. 

When iodide of potash is given in combination with mercury, you can 
begin with corrosive sublimate in doses of 0.0006 gramme (y^ grain) and 
gradually increase the dose. Corrosive sublimate is, however, so apt to 
cause disturbance of digestion that I prefer to treat these cases by giving 
the iodide of potash uncombined with any other drug, by the mouth, and 
applying mercurial ointment to the skin. 

The treatment of these later manifestations of syphilis must often be 
continued for long periods. 



Case 223. 



I have here, to illustrate the retarded form of syphilis, a girl (Case 222), thirteen years 
old. This case shows the importance of carefully reviewing the previous history not only 
of the child, but also of its parents. 

The mother has had only this child, has never had any miscarriages, has always been 
well, and has never shown any manifestations of syphilis. 

The father, so far as I can ascertain, until recently has 
always been well and strong, and has shown no signs of syphi- 
lis. About one year ago he began to have cerebral symptoms, 
which rapidly increased, were accompanied by paralysis, and 
were undoubtedly of syphilitic origin. 

I was first called to see this child when she was suffering 
from a mild attack of appendicitis, which did not come to oper- 
ation. At that time I noticed a peculiar conformation of the 
upper incisors, which made me at once suspect that I had 
under my care a case of hereditary syphilis. On further in- 
quiry I learned that she had been treated some years earlier 
by an oculist for keratitis. The upper incisors, as you see 
(Diagram 7), are abnormally far apart and stunted in their 
growth. They are notched, as is also the left lateral incisor, 
which is peg-shaped and by its clearly-cut notch represents 
more nearly than the others the characteristic syphilitic teeth. 
The right upper lateral incisor has a peculiar shape, the crown 
of the tooth coming down almost to a point. The other teeth 
are, as you see, in many places deprived of their dentine, and 
are in various stages of disorganization. 

On recovering from the appendicitis the child remained in 
a weak condition during the following year, looked sallow, and 
had continual headaches, which did not improve under the 
usual remedies. Treatment with iodide of potash has not only 
been followed by the disappearance of the headaches, but also 
has resulted in this healthy appearance of the child, who is 
perfectly well. 

Here is another illustration of what is probably 
the retarded form of syphilis. 

Probably retarded syphilis. 
This boy (Case 223) is seven years old, and is a negro. '^^^^^' " >'^^^ *-'*^^- 

His mother, who is said to be white, has had two miscarriages. 

The history of the father is not known, except that he was a negro. The boy has never 
had any disease, except measles when he was two or three years old. There is no history 




508 



PEDIATRICS. 



of his ever having had any of the earher manifestations of hereditary syphilis. "When he 
was four years old he had what were described as epileptiform convulsions, and since then 
he has had three or four of these attacks. The attacks come on suddenly, and he is very 
somnolent after they have passed off. Ever since he was four years old his abdomen has 
been more or less distended. His appetite is good, his bowels are regular. He has lately 
been brought to the hospital to be treated for headache, a distended abdomen, and dyspnoea. 

He has no enlarged glands, is not rhachitic, has no enlargement of the spleen and no 
ascites. The liver is found to be much enlarged, and, as you see, comes as low as the level 
of the umbilicus. Below the line of liver dulness the abdomen is resonant. The boy is 
mentally weak, and is very anaemic. On examination of his teeth you see that there are 
marked abnormal changes in the incisors. The upper four incisors are notched, dwarfed 
in size, and unnaturally far apart. The lower two middle incisors are also small and 
notched. 

I have been treating this boy for the past month with hydrargyrum cum creta by the 
mouth and with mercurial inunctions. Under this treatment his general health has much 
improved, and he does not display the same degree of mental hebetude that he did on 
entering the hospital ; he has also ceased to have the epileptiform attacks already referred to. 

(Under the mercurial treatment the boy made a most decided improvement in his 
general health. The liver decreased in size, the digestion and appetite improved, and he 
gained steadily in weight and in mental development. He was discharged four months 
after entering the hospital, apparently perfectly well, except that there was still a slight 
enlargement of the liver.) 



I have in this diagram represented twelve syphilitic teeth of the second 
dentition. They are all, as you see, more or less disorganized in a way 
Diagram 7 which might occur from any cause which 

would interfere with the normal develop- 
ment of the teeth and cause their early 
decay. The middle two and left lateral 
upper incisors show the notched and some- 
what peg-shaped condition which is sup- 
posed to be characteristic of syphilis, and 
which you see I have copied from the 
mouths of the girl and boy whom I have 
just shown you (Cases 222 and 223). 

As an illustration of these various 
will now show you a child who has been 




Syphilitic teeth of the second dentition. 



tertiary lesions of syphilis, I 

treated here in my clinic for some months. 



It is a girl (Case 224) , three and one-half years old. You will notice certain lesions on 
the face, arms, hands, and feet, which are the result of congenital syphilis. When this 
child was born it was apparently healthy. When it was three months old it was noticed to 
have occlusion of the nares, and at that time it had an attack of bronchitis lasting for three 
weeks. It is said that no efflorescence was ever noticed on its skin. When it was seven 
months old its hands began to swell, and at fourteen months the tissues around the meta- 
carpal bones of the little fingers of both hands became reddened and ulcerated and the 
fingers assumed the pyriform shape characteristic of syphilitic dactylitis. When the child 
was about sixteen months old, the feet began to swell, and in certain parts, especially the 
metatarsal bones of the right foot, the skin became reddened. When the child was three 
years old, pieces of dead bone began to come away from the hands, and this has since con- 
tinued. At this time also swellings began to appear over the upper maxillary bones, and, 
as you see, an extensive reddened and swollen condition of the tissues exists under the right 



SYPHILIS. 509 

eye. The fontanelles are closed. There are evidently a periostitis and an osteochondritis 
of the right arm, and there is also an enlargement of the left ankle, accompanied by ulcera- 
tion on the outer side of the malleolus. 

Case 224. 




Late manifestations of syphilis. Female, 3% years old. 

The child has been treated with the combination of mercury and iodide of potash such 
as you see in this prescription (Prescription 68) : 

Prescription 68. 

Metric. Apothecary. 

Gramma. 

03 R Hydrarg. chloridi corrosivi . gr. ss ; 

75 Potassii iodidi ^i ; 

00 Aq. destil 3ii. 



5t Hydrarg. chloridi corrosivi ... 
Potassii iodidi ........ 3 

Aq. destil. ......... 60 



M. M. 

S. — 2 CO. (^ drachm) 3 or 4 times in 24 hours. 

I have noticed that while it was taking this combination of drugs all its symptoms 
abated, it seemed better and brighter, and the lesions showed a tendency to heal. When- 
ever the medicine is omitted all the previous symptoms return. I should advise giving tho 
child much larger doses of the iodide than are contained in this prescription. 



510 



PEDIATRICS. 



The following case illustrates, among other interesting points, this same 
lesion of the bones. 

The boy (Case 225) is six years old. You will notice that he is rather pale, and that he 
has a somewhat peculiar frontal development, which well illustrates the form of syphilitic 
head to which I have already referred (Case 218). 

Case 225. 




Hereditary syphilis. Male, 6 years old. Abnormal prominences of frontal bone. 



You see the slight depression of the bridge of the nose and the bulging of the forehead 
on either side just above the orbital ridges. These prominences are accentuated by the deep 
sulcus between them, extending from the depressed nasal bones upward almost to the margin 
of the hair. This condition represents the typical syphilitic head. 

The boy is in fair health, and I can detect nothing abnormal about him on careful 
physical examination. His mother brings him to the clinic by my direction to receive, now 
that he is entering upon the period of the second dentition, a course of mercurial treatment 
for a few months. Possibly some iodide of potash may be given with benefit. 

He is a case of probable recovery from hereditary syphilis, as up to the present time he 
has practically been cured. The various lesions of the bones and in the organs which it is 
necessary now to guard against correspond to the later lesions of acquired syphilis, and 
hence my reference to the use of iodide of potash, which in conjunction with mercury is of 
great value in these later manifestations of syphilis, and will be given to him in the form of 
the stronger chloride of mercury in combination with the iodide of potash. 

The mother of this boy first brought him to see me at the Children's Hospital when he 
was six weeks old. The mother had been well and strong, and had never had any other 
children nor any miscarriages. The father had had a primary syphilitic lesion one year pre- 
vious to the birth of the child, which was followed by secondary manifestations. The mother 
had plenty of good breast-milk, and nursed her infant until he was nineteen months old. 
The infant was never atrophic, and though pale was apparently well nourished. At birth 
he showed a bullous efflorescence of medium grade. During the early weeks of his life 
he did not receive any medical treatment, although he had a general efflorescence of 



SYPHILIS. 511 

macules, pustules, and bullae. At about the fifth week he lost the use of his left arm. 
When seen by me at the sixth week he showed a number of lesions besides those described, 
and it was doubtful if he would live. These lesions consisted of fissures at the corners of 
the mouth, mucous patches in the mouth, condylomata of the anus, and occluded nares. 
There was not at that time the peculiarly formed head which is now present. The left arm 
was helpless and was supposed to be broken ; in fact, there was some crepitation, and prob- 
ably there was a slight separation of the epiphysis of the distal end of the humerus. There 
seemed to be considerable pain in the arm, which made the infant restless and fretful. In- 
somnia was a prominent symptom. The arm was put in a light splint, and the oleate of 
mercury ointment (Prescription 66, page 499) was ordered. 

The infant was then not seen for a week. On being brought back to the hospital the 
right arm was found to be helpless, and the mother stated that the ointment had been dis- 
continued, as it caused excoriation of the skin. The ointment was then reduced one-half 
with lanoline, and hydrargyrum cum creta was given three times daily in doses of 0.06 
gramme (1 grain). 

In three days the infant was much better, the paralysis soon disappeared, and nothing 
abnormal was detected about the arms. The hydrargyrum cum creta was increased to 0.24 
gramme (4 grains), but, as this caused diarrhoea, the dose in a few days had to be reduced to 
0.18 gramme (3 grains). In the course of the next month the nasal symptoms and the 
efflorescence had disappeared, and the infant seemed perfectly well. 

Six months later it was brought back to the hospital with a return of the condylomata 
and a slight papular efflorescence. The same treatment as before was carried out. The 
syphilitic manifestations disappeared, and have not returned since. 

The child was kept under observation and treated from time to time for three or four 
years. The first teeth were cut at nine months, and, as you see, are in fair condition to-day. 

In connection with this case, and for the purpose of aiding you in your differential 
diagnosis where an apparent paralysis is present, I would state that the possibility of the 
paralysis being a poliomyelitis anterior acuta was considered, but hardly seemed to explain 
the symptoms and the result, both arms being affected and entire recovery taking place three 
days after the mercurial treatment was properly carried out. Pain, also, would not have 
been present in a poliomyelitis. A central lesion was then thought of, but the rapid re- 
covery from the paralysis before the efflorescence or the occluded nares had begun to be 
affected seemed to show that such a lesion did not exist. The evident pain experienced by 
the child when the arms were touched, and the speedy disappearance of this sensitiveness, 
as well as of the paralysis, under mercurial treatment, pointed towards a lesion in the arms 
themselves. The infant did not choose to lift or use its arms, because moving them caused 
pain. No traumatic history could be obtained. Rheumatism occurring at six weeks of 
age and affecting a child in this peculiar way would be very uncommon. 



512 PEDIATRICS. 



IvECTTURK XXIII. 

ERYSIPELAS. 

The term erysipelas is applied to an inflammation of the skin, sub- 
cutaneous tissue, and mucous membranes which has the following charac- 
teristics. It especially involves the lymph-spaces and lymph- vessels. It 
has a tendency to spread, and is attended by unusual swelling of the subcu- 
taneous tissue and an intense red color of the skin or the mucous membrane. 
In addition to these local appearances it is accompanied by constitutional 
symptoms, which are mostly the result of a heightened temperature. 

It is caused by a micrococcus which is found exclusively in the lymph- 
spaces of the skin. This organism is a streptococcus, and in all probability 
is identical with the streptococcus pyogenes. The former belief that there 
existed a special organism which caused erysipelas has not been supported 
by recent investigations. 

The disease runs an acute course, is contagious, enters the individual 
through some abrasion of the skin or mucous membrane, and is self-limited. 
The most careful and complete work which has been done in studymg this 
disease is by Fehleisen. 

Pathology. — According to Delafield and Prudden, the tissues may be 
swollen by an accumulation of serous fluid. This fluid may be nearly 
transparent, or may be turbid from admixture with pus-cells. The pus- 
cells may infiltrate the tissues either sparsely or in dense masses. Sometimes 
vesicles are found on the surface, or there may be crusts. Sometimes more 
or less of the affected region is filled with abscesses or becomes gangrenous. 
In some cases, aside from the local lesions petechise are found in the serous 
membranes, and swelling of the spleen and parenchymatous degeneration of 
the kidneys and liver. When the mucous membranes are afi*ected they 
show the same appearances as the lesions of the skin, except so far as these 
are modified by the difPerent structure of the tissue. The disease may attack 
the larynx and upper air-passages and may result in oedema. Pneumonia 
may occur as a complication. 

Although the different organs, such as the spleen, kidney, heart, and 
liver, at times show pathological changes, nothing characteristic of erysipelas 
has been found in these organs, but only such changes as may occur from a 
continued high temperature or as the result of sepsis. 

Erysipelas may be divided into two forms, (1) mig^^ans, extending from 
surface to surface, and (2) ambulmis, occurring in different parts of the skin. 
It may also be acute or chronic. 

In erysipelas migrans, which is the most common form, the whole surface 



ERYSIPELAS. 513 

of the body may be attacked. It is very prone to return, passing over the 
same surfaces of the skin again. The face and head are not so commonly 
attacked in infants as in adults, and the disease seldom spreads from another 
part of the body to the head. When it does attack the head, it is apt to be 
fatal from a secondary purulent meningitis. It at times causes great swell- 
ing and tension, and may go on to gangrene in certain localities, such as the 
scrotum. 

After the first year erysipelas so closely resembles the disease as it occurs 
in adults that we need not consider it in this later period of life. It is a 
somewhat frequent disease in infants up to six months of age. It then be- 
comes less frequent up to the first year, and after that and in childhood is 
rather rare. I shall, therefore, speak of erysipelas as it afPects infants only. 

The erysipelas of infancy may be divided into (1) erysipelas of the new- 
born and (2) erysipelas of sucklings. 

ERYSIPELAS OP THE NEW-BORN.— Where erysipelas occurs 
before the end of the third week the infant seldom lives, and indeed it is a 
most dangerous disease up to the end of the third or fourth month. Ery- 
sipelas of the new-born is apt to occur during an epidemic of puerperal 
fever. If the mother has any septic symptoms, the infant should be imme- 
diately taken away from her. I have seen a case where the mother had 
puerperal peritonitis following her delivery and where the infant (Case 226), 
who was allowed to nurse her, was attacked by erysipelas. 

In many cases occurring in the early days of life the disease starts on 
the genitals, and may be complicated by other diseases, such as empyema 
and especially pneumonia. During the course of the disease the fontanelle 
sinks, the spleen is enlarged, convulsions may occur, and peritonitis accom- 
panied by vomiting may arise as a complication. The disease is liable to 
invade the tissues at any point of abrasion, whether from the forceps or 
from vaccination, or at the point of separation of the umbilical cord. The 
latter is the most common locality for the infection to take place. From 
this point the infection may extend and produce a gangrenous condition of 
the stomach or abdomen. 

Although the temperature in the early hours or even days of the disease 
may not be raised, yet, as a rule, fever soon appears, the temperature varying 
from 39° to 41° C. (102.2° to 105.8° F.). Reddening and swelling, not 
of a high grade at first, appear on the parts affected. The infants show 
symptoms of a general sepsis. Vomiting frequently occurs, followed by 
oollapse and almost without exception by death. 

Treatment. — ^The treatment of this severe form of erysipelas is by 
stimulants and a substitute food adapted to the infant's digestion. 

ERYSIPELAS OP SUCKLINGS.— The stage of the incubation of 
erysipelas lasts, according to Osier, from three to seven days. 

When the disease occurs in the early months of life, its beginning is 
usually accompanied by cold extremities and collapse. The tem})crature is 
raised, and the higher its degree the graver the prognosis. The temperature 



514 PEDIATRICS. 

curve, as a rule, shows a zigzag course, except in the more severe forms, 
where there is continued high fever with which icterus is apt to be combined. 

The efflorescence, although very similar to that which is seen on the 
adult's skin, differs somewhat on account of the more delicate structure of the 
infant's skin. It begins as a faint erythema, which spreads rapidly and as 
quickly disappears, perhaps in twenty-four hours, and twenty-four hours 
later desquamation may occur. The light color of the efflorescence soon 
becomes darker and more intense, and is accompanied by swelling, heat, and 
tension of the subcutaneous tissue. After the efflorescence has continued 
for a certain number of days, depending upon the amount of the surface of 
the skin involved, the extension of the disease ceases and the temperature 
falls. The redness gradually disappears, and the skin becomes covered with 
yellowish-brown crusts. Finally, desquamation takes place, and the skin 
recovers its normal appearance, the disease extending over a variable period 
according to the greater or less extent of the surfaces invaded. 

Although the disease when involving large surfaces is dangerous, yet 
cases in the later months of infancy recover even where the attack has been 
a severe one. An instance of this kind came to my notice where an infant 
ten months old was attacked with erysipelas, the point of infection being 
the right labium. 

In this case (Case 227) the whole vulva shortly became very tender and the disease 
extended to the pubes and abdomen. It invaded every part of the body and extremities 
and the head and neck. The eyelids and lips were the last points of attack. Even the 
palms of the hands and soles of the feet were affected. Prom the time that it appeared at 
one part of the body until the skin of that part assumed its normal color again was four 
days. When the erysipelatous inflammation extended to the feet there was marked oedema. 
The duration of the attack from its first appearance at the vulva to its disappearance at the 
eyes and mouth was about fifteen days. The infant was treated with small doses of iron 
and quinine, and recovered entirely. 

Treatment. — No treatment of which I know is of any avail in cutting 
short the disease. Where large surfaces are affected, the application of cold 
compresses tends to depress the vitality of the infant, which it is so important 
to sustain. During the height of the disease the infant's strength should 
be supported by stimulants and by the frequent administration of a food 
adjusted to its digestion. 

I have here an infant (Case 228, Plate VI., facing page 504) six 
months old which represents the typical efflorescence of the erysipelas of 
sucklings. 

It is a female, has always been healthy, and was nursed by its mother until within the 
last three weeks, when it was weaned from the mother and nursed by another woman. It 
is of normal weight and general development. 

The first symptoms which were noticed were that it began to vomit and to have a raised 
temperature, 39.5° C. (103.5° F.) in the axilla. It seemed weak and languid, looked badly, 
and refused to take the breast. An examination of the breast-milk showed a peculiar green 
color, which not only appeared in the milk when drawn from the breast, but also, when the 
analysis was made, appeared in the curd resulting from the precipitation of the proteids. 



ERYSIPELAS. 515 

The analysis (Analysis 60) of the milk was as follows. The nature of the micro-organism 
which produced the green color was not determined. 

ANALYSIS 60. 

Fat 4.56 

Sugar 6.36 

Proteids 3.46 

Ash 0.13 

Later in the day a pink efflorescence appeared just above the pubes, and there was found 
to be considerable irritation in the neighborhood of the vagina. The redness extended from 
the vagina to the supra-pubic efflorescence. The efflorescence was of an erythematous type. 
On the following day it spread to the left thigh, and then to the left lower leg. The tem- 
perature continued to be raised, and the infant refused to nurse. Small quantities of a 
substitute food with the following percentages (Prescription 69) , which had to be varied from 
day to day, were given to it : 

Prescription 69. 

Fat - 2.50 

Sugar 6.00 

Proteids 1.50 



There were no convulsions or other symptoms, but the infant lost somewhat in strength 
and weight and its face looked pinched. 

The efflorescence on the left leg began to fade on the ninth day of the disease, and on 
the tenth day the temperature became almost normal. On the following day, however, it 
again rose, and a fresh efflorescence began to appear on the right thigh continuous with the 

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Erysipelas of legs. Female, 6 mouths old. 



efflorescence of the supra-pubic region. This efflorescence extended down the right leg to 
the ankle, and you see the condition of it to-day. 

You will notice certain points in regard to the efflorescence on the left leg. A slight 
amount of redness is present, but it has mostly disappeared, leaving the skin in parts in an 
almost normal condition, in other parts covered by thin brownish-yellow crusts. The supra- 



516 PEDIATRICS. 

pubic region and the right leg as far as the ankle are, as you see, covered with a bright red 
efflorescence sharply bounded by normal skin below, just above the ankle, as though it were 
a stocking. The whole leg is swollen, is hotter to the touch than the sound skin, and 
presents a somewhat raised, glistening appearance. 

No external applications and no drugs have been employed in this case. The milk 
has been carefully modified, and small doses of brandy have been given. 

(The subsequent history of the case is as follows. A few days later the temperature 
became normal, the efflorescence began to fade, desquamation subsequently took place, 
and the skin finally recovered its normal appearance. The infant gradually regained its 
strength, became perfectly well, and has had no return of the disease.) 

Here is the chart (Chart 10, page 515) showing the temperature during the course of the 
erysipelas in this case. 

This form of erysipelas may become chronic, and this is more apt to 
occur in children than in infants. It is also most common in children who 
are in a debilitated condition, and may occur at intervals of three or four 
years. It is frequently in older children connected with chronic inflam- 
mations of the Schneiderian membrane, and in these cases is peculiarly in- 
tractable to treatment. 



THE EXANTHEMATA. 517 



THE EXANTHEMATA. 

Variola — Varicella. 

In contradistinction to the various diseases of the skin which dermatolo- 
gists are accustomed to designate as exanthems of local origin are certain 
acute, specific, infectious diseases which they call the exanthemata. This 
class of cases is of especial interest in connection with diseases which arise 
in children, as it is among children that they most frequently occur. They 
can, however, attack individuals of any age. Although none of these dis- 
eases are entirely self-protective, yet the instances in which they develop in 
an individual more than once are rare. 

The exanthemata comprise five diseases, — variola (small-pox), varicella 
(chicken-pox), scarlet fever, measles, and rubella. In regard to the latter 
there is a question whether it is a disease distinct from measles. 

This group of diseases is characterized by certain conditions common 
to all. Besides being infectious, each disease runs a definite course and is 
self-limited, facts which should be remembered when we are studying its 
diagnosis and treatment. 

The course of these diseases from the time when the infection takes place 
up to the appearance of their later manifestations may be divided into dis- 
tinct stages. In the first of these certain micro-organisms are supposed to 
enter the system, and, so far as external appearances and general symptoms 
are concerned, to remain dormant for a time, constituting what is called the 
stage of incubation. This stage of incubation is followed by certain general 
symptoms resulting from the supposed development of the special organisms 
and constituting the prodromal stage. These prodromal symptoms are, 
after intervals varying according to the special disease, followed by an 
efflorescence on the skin, which marks the third stage of the disease, called 
the stage of efflorescence. The efflorescence in its turn is followed by what 
is called the stage of desquamation, this desquamation being more or less 
pronounced in proportion to the intensity of the lesions of the skin which 
have occurred during the stage of efflorescence. 

Although in a large number of cases the diagnosis of these diseases can 
be determined by the appearance of the efflorescence and its location, yet 
instances occur not infrequently where the efflorescence is very misleading. 
"We should, therefore, be familiar with the characteristics of the other stages 
of these diseases, for it is by carefully considering the pictures which they 
present to us as a whole that we are enabled to make a correct differential 
diagnosis of the especial case. Thus, a papular efflorescence, although signi- 



518 PEDIATRICS. 

ficant in most cases of measles, may also be present in any other member of 
the group, while an erythema closely resembling scarlet fever may occur in 
variola, measles, or rubella. 

VARIOLA (Small-Pox). — The first disease of this group which I shall 
speak of is variola. Variola is one of the most virulent of the infectious 
diseases with which we have to deal, and is particularly fatal among infants 
and young children. It is an acute disease, caused evidently by a micro- 
organism. It is characterized by severe constitutional symptoms, accom- 
panied by a progressive efflorescence from macules and papules to vesicles 
and pustules, followed by the formation of crusts, these lesions having a 
tendency to result in cicatrices. As I have stated to yon in a previous 
lecture (Lecture V., page 147), since vaccination has been established, variola, 
in contradistinction to varicella, scarlet fever, and measles, is an extremely 
rare disease among infants and young children who have been vaccinated. 

Although there are no characteristics of variola which are distinctive in 
children from those of the disease occurring in adults, it is important to 
recognize its chief features for the purpose of differential diagnosis. It is 
possible for the foetus to contract the disease in utero. This, however, is 
rare, and it is well known that infants whose mothers are affected with 
variola can, even when born in small-pox hospitals, be protected from the 
disease if vaccinated immediately. It is rather remarkable that the micro- 
organism which causes variola has never been discovered, when we consider 
for how long a time the disease has been known to be highly infectious. 
The contagium is supposed to exist in the secretions and excretions, and to 
emanate from the exhalations of the lungs and from the skin. It is in all 
probability transmitted principally by means of particles of the crusts. It 
has a wonderful tenacity for clothing or any like means of conveyance. It 
has been proved that the contagium is active before the efflorescence occurs, 
though not so much so as later. It has also been fairly well proved that 
its activity ceases when all the crusts have fallen off and when the entire 
skin has become smooth. The most virulent form of the disease can be 
contracted from a mild form, such as varioloid. 

Pathology. — The pathological conditions found in variola are chiefly 
those of the skin and the mucous membranes. 

According to Weigert, the progressive changes of the lesion of variola 
are as follows. The lesion begins as a round, somewhat raised macule. 
This develops into a hard papule, and later a small vesicle arises on its sum- 
mit. This vesicle enlarges very rapidly and changes to a tensely filled pus- 
tule with a central depression. The size of this pustule corresponds to that 
of the original macule. Microscopically the macule consists of a circum- 
scribed spot of hypersemia in the capillary layer of the skin. The papule is 
formed by a sharply defined necrobiotic degeneration of the under layers of 
the rete mucosum, by which process the nuclei of the epithelial cells are de- 
stroyed. By the transudation of fluid into these areas the cells are pushed 
apart and the epithelial layer is lifted up as a whole, covering the area 



THE EXANTHEMATA. 519 

affected, and forms a vesicle the inner part of which is composed of a mesh- 
work filled with lymph. In the vicinity of the necrobiotic focus an inflam- 
mation is set up, causing an increased growth of the cells of the rete which 
surround and wall in the focus on all sides. The developed pustule extends 
through the whole thickness of the cutis to the subcutaneous tissue. A net- 
work inside the pustule, which is most tense in the central part, connects 
the roof and floor of the pustule, and, in conjunction ^ith the above men- 
tioned growth of the cells of the rete around the focus, causes the central 
depression. If the vesicle is pricked, only a part of the lymph flows out 
of the mesh-work within. The lymph is clear, and contains some wliite 
and red blood-corpuscles, streptococci and staphylococci, fibrin-flocculi, and 
molecular granules. The contents of the pustule are purulent, and those 
in the hemorrhagic form contain blood. Cliunps of bacteria with analogous 
localized degeneration and its associated changes are found in the neighbor- 
hood of the pustules, also in the parenchyma of the iuternal organs and 
lymph-glands, as well as in the skiu. When the variola has reached its 
height the central depression in the pustule disappears, because the increased 
tension iu the contents tears away the mesh-work. The vesiculation begins 
in the upper central part and spreads downward towards the periphery. 
The pustule then collapses and changes to a crust, which after a certain 
number of days falls off, leaviag a more or less deep scar covered with 
young epithelium. A distinct difference iu the anatomy of a pustule of 
variola vera and one of varioloid does not exist. 

On the mucous membranes of the mouth, nose, conjunctivae, bronchi, 
oesophagus, rectum, sometimes the vagina, and also on the tonsils and the 
tongue, the same pustular efflorescence may be found, and is either superficial 
or extends more deeply. At times also a pseudo-membrane is foimd on the 
ulcers. 

According to Osier, the papillae of the true skhi below the pustules are 
swollen and infiltrated with embryonic cells to a variable degree. If the 
suppuration extends into this layer, scarring invariably results ; it does not 
necessarily follow if the suppuration is confined to the upper layer. 

In the intestiues swelling of Peyer's follicles is not imcommon. In 
the larynx the efflorescence may be associated with a fibrin exudate, and 
sometimes with oedema sufflcient to cause death. Occasionally the inflam- 
mation extends deeper and involves the cartilages. In the trachea and 
bronchi there may be ulcerative erosions, but the characteristic lesions seen 
on the skin do not occur. There are no special lesions of the lungs, but 
congestion or broncho-pneumonia is very common. 

According to Gardner, in addition to the conjunctiva almost every part 
of the eye may suffer, the lids, lachrymal sac, cornea, choroid, and even the 
retina and extrinsic muscles. 

These complications may occur either during the course of the disease or 
afterwards. 

According.to Adler, keratitis may develop from a purulent conjunctivitis, 



520 PEDIATRICS. 

or quite independently of it, never, however, earlier than the twelfth day. 
It may occur as a circumscribed superficial inflammation which, even under 
atropine and hot fomentations, may take the form of an ulceration very 
dangerous to the eye. 

In the ear, according to Wendt, complications are more frequent than in 
the eye. The milder forms of hypersemia are generally overlooked, as they 
cause no symptoms. Congestion of the middle ear is common, and is generally 
directly due to swelling of the naso-pharyngeal mucous membrane closing 
the Eustachian tubes. Sometimes this progresses to acute inflammation of 
the middle ear, which may end in extensive destruction of the soft parts, with 
subsequent permanent deafness. 

According to Osier, in exceptionally rare cases the eruption extends 
down to the oesophagus and even into the stomach. 

The pathological changes in the other organs consist of enlargement of 
the spleen and fatty degeneration of the liver, kidneys, and heart. Meta- 
static processes in the various organs and in the joints sometimes occur. In 
the hemorrhagic form hemorrhages in the various cavities in the different 
organs, and, according to Golgi, in the medullary cavities of the bones, may 
occur, also in the serous and mucous surfaces and in the muscles. 

Incubation. — The incubation of the disease varies from twelve to four- 
teen days, the latter being the most frequent period. 

Symptoms. — According as the symptoms of variola are mild or severe 
the disease has been divided into a number of forms, designated as follows : 
(1) discrete, (2) confluent, (3) hemorrhagic, and (4) modified. In all these 
forms the initial fever, convulsions, and general symptoms may be severe, 
and do not necessarily indicate which type of the disease is about to 
follow. 

(1) Discrete. — The mildest and most typical form of the disease is 
that which is called discrete. 

Prodromata. — In this form, the invasion, though sometimes less severe 
than in the confluent and hemorrhagic forms, as I have just stated, in infants 
and young children is almost always of a grave type. In infancy and early 
childhood the disease commonly begins with convulsions. There may be 
vomiting, great restlessness, quick pulse, high temperature, and in a number 
of cases the children quickly succumb to the disease from the virulence of 
the toxaemia. If they survive this early stage of the disease they usually 
present the same sequence of symptoms as in cases occurring in later life, but 
may eventually die from the exhaustion which often rises from a prolonged 
suppurative fever. In the prodromal stage the pulse is much quickened, 
and the temperature may be as high as 40°, 40.5°, or even 41.1° C. (104°, 
105°, or 106° F.). In this stage we at times, especially among children, 
meet with an evanescent erythematous efflorescence. According to Simon, 
this manifestation is distinct from that of scarlet fever. It has a peculiar 
distribution and generally a limited extent, usually affecting the lower ab- 
dominal areas, the inner surface of the thighs, the sides of the thorax, and 



THE EXANTHEMATA. 621 

the axillae ; sometimes, however, it involves the whole surface. This efflo- 
rescence is distinct from the typical lesions of variola w^hich occur later. 

Efflorescence. — On the third or fourth day of the prodromal symptoms 
an efflorescence appears on the skin, and at this time the frequency of the 
pulse lessens, the temperature usually falls considerably, and the more severe 
symptoms improve, so that the patient appears much more comfortable. The 
efflorescence is at first represented by small red macules or papules, which, as 
a rule, first appear on the forehead, or on the face and mucous membranes, 
and later on the trunk and limbs. The papules are rather scattered in their 
distribution, and have a feeling as of shot under the skin. The macules 
when present soon become papules. On the third day by means of a good 
light a small vesicle can be seen at the apex of the papule, and by the fifth 
or sixth day the vesicular stage is well established and the vesicle becomes 
distinctly umbilicated. This appearance on careful examination can also be 
seen in the lesions of the mucous membranes. At about the eighth day the 
vesicles become pustules, the tops soon flatten, and the umbilication dis- 
appears, leaving an areola of injection and the intervening skin swollen. 

The temperature at this time rises, from the suppuration which is taking 
place in the pustules. This rise of temperature is called the secondary 
fever, or fever of suppuration. The temperature remains high for from 
twenty-four to forty-eight hours, and then gradually falls until by the 
twelfth or thirteenth day it usually becomes normal. The contents of the 
pustules dry up, and crusts are formed. On the palms and soles small hard 
disks form, which may of themselves fall off in infants, but in children as 
old as ten years would remain for a long time unless removed w^ith the point 
of a knife. 

Desquamation. — By the fourteenth or fifteenth day the stage of des- 
quamation is established. In some cases extensive scars are left on the skin 
where the crusts have fallen off. This is most apt to occur in severe cases. 

(2) Confluent. — In contradistinction to the mild or discrete form 
of variola is the more severe form, called confluent, on account of the ten- 
dency of the lesions to coalesce. In the confluent form of variola the efflo- 
rescence usually appears at the same time as in the discrete form. At about 
the fourth day the lesions become confluent, the skin becomes reddened and 
swollen, and the face may be much distorted by the severity of the lesions. 
In this form the initial temperature does not fall to the same degree as it 
does in the discrete form, and, according to Sydenham, diarrhoea is likely 
to occur, particularly in children. The pharynx and larynx are especially 
apt to be involved, and the cervical lymphatics to be enlarged. The crusts 
adhere longer in the stage of desquamation than they do in that of the same 
stage of the discrete form. 

(3) Hemorrhagic. — The third or hemorrhagic is the most \'irulent form 
of variola, and may occur in children as it does in adults, though not so 
frequent in the former as in the latter. Its symptoms in children are so 
severe that in almost every case it very quickly proves fatal. It is charac- 



522 PEDIATRICS. 

terized by punctiform hemorrhages in the skin, appearing from the first to 
the fourth day of the prodromal stage, ecchymoses in the conjunctivae, and 
hemorrhages from the mucous membranes. According to Osier, hsematuria 
is the most common form of hemorrhage, hsematemesis the next. 

(4) Modified Form. — The fourth or modified form of variola is where 
the disease attacks individuals who have been successfully vaccinated. This 
form is called varioloid, but would be better termed " modified small-pox.'^ 
Modified small-pox is usually much milder in its symptoms than any of 
the other forms of variola, although the initial fever may be as high as in a 
severe case. The papules are fewer in number, the temperature becomes 
normal sooner, and the child seems comfortable in a shorter period of time, 
since there is usually no secondary fever from suppuration. The nearer the 
attack comes to the time when the child was vaccinated, the less severe will 
be the symptoms. 

In any of these forms of variola the prodromal symptoms may be of a 
very severe nervous type, and this is especially characteristic of the disease 
as it occurs in children. For this reason variola may simulate other dis- 
eases in its prodromal stage, and may often cause death before the efflores- 
cence has appeared. This is especially the case with the prodromal symp- 
toms of the hemorrhagic form. 

Complications. — The most common complications of variola are those 
of the larynx and the lungs. Where the larynx is affected, oedema of the 
glottis may suddenly arise and death take place from suffocation. 

In the throat the presence of the efflorescence occasions great irritation, 
and the accompanying secretions cause nausea and at times dyspnoea, with 
a cough which in weak children is very exhausting. 

Where acute inflammation of the middle ear has taken place the pain 
during the formation of the pus is very intense, but it subsides as soon as 
the sac bursts or is incised. This complication, therefore, requires early 
and careful treatment. 

Where a lesion of the lung develops, it is usually in the form of a 
broncho-pneumonia. Lobar pneumonia rarely complicates the disease. 

Although albumin is very frequently present in the course of the disease, 
nephritis is rare. 

This chart (Chart 11, page 523) represents the usual temperature curve 
of the initial fever and suppurative fever of a typical case of variola. 

Diagnosis. — There is no other constitutional disease accompanied by an 
efflorescence on the skin which in a typical case would be likely to be mis- 
taken for variola. The severe constitutional symptoms, the slowly develop- 
ing and rather scattered macules and papules, with the shotty feeling of the 
latter, the umbilicated vesicles gradually becoming pustules, the extensive 
crust formation, and the initial and suppurative fever, all render the diag- 
nosis in most cases quite plain. 

In making the diagnosis of variola we should consider that the disease 
differs materially in its prodromal symptoms from varicella and measles. 



THE EXANTHEMATA. 



523 



The almost complete absence of prodromal symptoms in varicella, and 
the pronomiced catarrhal symptoms of the nose and eye in measles, make 
the differentiation from these diseases comparatively easy. Although the 
prodromal symptoms of scarlet fever and of variola are often of equal 















CHART 


11. 
















JDdlfS ofDzSGCtSG 




F 


1 


2 


3 


4 


5 


6 


7 


8 


9 


10 


II 


12 


13 


14 


c 


107° 
106° 
105° 
104° 
103° 
102° 
\<^ 
100° 
99° 

NOOM'L 
rE«P. 

98° 
97° 
96° 
95° 


M E 


M £ 


M E 


M E 


^Te 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


41.6° 

41.1° 

40.5° 

40.0° 

39.4° 

38.8° 

38.3° 

37.7° 

37^° 
37.0° 

36 6° 

36.1° 
35.5° 
35.0° 
































/ 


























^ 


/ 


\a 










/ 


^ 












/ 




V 










/ 




\ 










/ 












1 


f 




u 










/ 










/ 


y 








, 








/ 






/ 


V 


/ 










u 








/ 






M 
















\ . 


A 






















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'"' 1 



Fever of invasion. Fever of suppuration. 
Variola. 

severity and somewhat similar, such as the convulsions and vomiting, yet 
the pronounced symptoms connected with the throat in scarlet fever, and 
the appearance of an erythematous efflorescence instead of the scattered 
papules of variola, serve to differentiate clearly the two diseases. We 
must, however, be careful not to mistake the evanescent efflorescence wliich 
I have already referred to as occurring in the prodromal stage of variola 
for the erythema of scarlet fever. The distinction can usually be made by 
remembering that this efflorescence in variola affects the particular areas of 
the skin already referred to, and that these areas in scarlet fever, measles, 
and varicella are unlikely to be affected early in the stage of efflorescence. 
The typical location of the efflorescence of scarlet fever is first on the neck 
and chest, that of measles on the face, and that of varicella on the back, 
face, and head. 

In making the diagnosis of variola we must, of course, bear in mind the 
efflorescence which appears on the skin as the result of vaccination, and that 
which occurs in the course of the disease vaccinia. In vaccination the single 
lesion and the absence of severe constitutional symptoms make it haixily 
necessarv to do more than refer to it in this connection. The differential 
diagnosis from vaccinia is not difficult, and yet this disease is so rare that 
when it appears it almost always creates a suspicion that we may be dealing 
with variola. As a rule, in vaccinia the general symptoms are not severe, 



524 PEDIATKICS. 

the disease being represented almost entirely by a slight malaise and loss of 
appetite, in conjunction with the appearance on the third or fourth day of 
an efflorescence on the skin. This efflorescence, as I have stated in a pre- 
vious lecture (Lecture V., page 152), is represented by papules, vesicles, and 
pustules, few in number and irregularly distributed, some on the face and 
nose and a few on the body and extremities. As the disease almost inva- 
riably appears after vaccination, this fact is of great aid in differentiating 
it from variola. The subsequent course of a case of vaccinia is so much 
milder and shorter than that of variola that in a few days the differential 
diagnosis can be made easily. 

Treatment. — There is no specific treatment for variola, but it is of the 
utmost importance that the best hygienic care should be employed. The air 
of the room should be perfectly fresh. The crusts should be kept softened with 
a mixture of glycerin, oil, and carbolic acid, and the odor arising from them 
should be modified by the application of a dilute solution of carbolic acid. 

In the initial stage of the disease stimulants should be freely given if 
the symptoms are severe, and the high temperature should be controlled by 
sponging with water at a temperature corresponding to the power of the 
child's reaction. 

The greatest care should be taken during the stage of convalescence, 
and when the child is considered well the most rigid measures for prevent- 
ing the spread of the contagium should be enforced. The clothing and 
everything connected with the child and its attendants, and the room in 
which they have been kept during the sickness of the child, should be 
thoroughly disinfected, the same precautions being taken to prevent the 
spread of variola that I shall presently describe to you in speaking of scarlet 
fever (Lecture XXV., page 549). The immediate transferrence of a patient 
from its room to a small-pox hospital is in most communities considered the 
wisest method of dealing with the disease, and is usually enforced by law. 

VARICELLA (Chicken-Pox). — The next member of the group of ex- 
anthemata which I shall speak of is varicella. It is the mildest in its 
symptoms and the most favorable in its prognosis of the whole group. It 
is highly infectious, and is characterized, in distinction from the other exan- 
themata, by its long stage of incubation, the shortness or absence of the 
prodromal stage, vesicular efflorescence, and absence of sequelae. Vari- 
cella has been known as an independent disease for the last two centuries. 
At one time it was not clearly differentiated from measles and scarlet fever, 
and in some parts of the world it is supposed to be closely allied to variola. 
This opinion, however, is not generally substantiated, and we can accept 
varicella as a distinct disease. 

It can occur at any age, but the most common time for its appearance is 
in the middle and latter part of the first year. It continues to be a common 
disease all through the early and middle years of childhood. The suscepti- 
bility to the contagium of varicella lessens after ten years of age, and almost 
disappears at puberty. It is sometimes sporadic and sometimes epidemic. 



THE EXANTHEMATA. 525 

It occurs with equal frequency at all periods of the year. The vehicle of 
contagium is not known, but it probably enters the system by the lungs. 
The specific organism which produces varicella has not yet been determined. 

Pathology.— Deaths from varicella are so extremely rare that our 
knowledge of the pathology of the disease is necessarily limited. It is 
evident, however, that the efflorescence of vesicles, which represents the 
principal morbid lesion of the disease, is of a somewhat different type from 
that which occurs in variola. The vesicle is much nearer the surface than 
in the latter disease, being formed mostly by the upper layers of the 
epithelium. The vesicle itself is seldom multilocular, a condition which is 
frequently present in variola. The contents of the vesicles are usually a 
clear serum, the progression to a pustule being rare in comparison with the 
lesion of variola. The lesion so rarely involves the deeper layers of the 
skin, and the process is usually so very mild, that it is seldom that suffi- 
cient destruction of the tissue takes place to produce a scar. 

The lesions may appear on the mucous membranes as well as on the 
skin. At times the lesions assume a much more serious form and may 
become gangrenous. In gangrenous varicella, according to Eustace Smith, 
the vesicles, instead of drying up in the ordinary way, become black and 
larger, so that a number of rounded black crusts are scattered over the 
surface of the body. If a crust be removed, it is found to cover an ulcer 
more or less deep. Around it the skin is of a dusky red color. All the 
vesicles do not become gangrenous, so that we find crusts of the ordinary 
appearance mixing with the blackened crusts. The gangrenous process 
often penetrates deeply through the skin to the muscles. The lesions at 
times are so extensive as to form ulcers which may invade and destroy 
large areas of tissue. 

Incubation. — The stage of incubation is variable, but lasts from eight 
or ten days to three weeks, the usual time being about seventeen or eighteen 
days. 

Symptoms. — Prodromata. — There are rarely any prodromata in vari- 
cella, beyond a slight malaise for a few hours. At times, however, especially 
in young infants, the onset of the disease may be severe : it may be charac- 
terized by vomiting, and, where the temperature is high, even by convulsions. 
In rare cases the prodromal stage is of considerable length and the prodro- 
mata resemble somewhat those of the other exanthemata. 

Eflaorescence. — The disease usually shows itself in the form of an 
efflorescence, the characteristic and most common lesion of which is a 
vesicle. The lesion, however, is in the beginning a macule, which quickly 
becomes a papule, and the papule so rapidly develops into a vesicle that it 
is in the vesicular stage that we usually first notice the efflorescence. These 
macules and papules are so superficial that they are soft to the touch and do 
not give the shotty feeling which is so common in these lesions when they 
occur in variola. The vesicle of varicella, as a rule, is not unibilicated, 
and but rarely do its contents become pustular. It may be surrounded 



526 PEDIATRICS. 

by a light red areola, but this is not present in all the lesions. The usual 
course of progression in the lesions is that the vesicle flattens, its contents 
are dispersed on the skin or absorbed, and a small crust is formed, which 
finally falls off, leaving the skin smooth and without a scar. Occasion- 
ally a scar results from some individual lesion in which the inflammatory 
process has involved the deeper layers of the skin. The efflorescence is 
irregular and general in its distribution, the lesions appearing on the face 
and head, in my experience especially behind the ears, on the body, usually 
first on the back, and finally on the extremities. It comes out in succes- 
sive crops, so that very different lesions may be found on the skin at once, 
representing the early and late manifestations of the efflorescence. It, how- 
ever, may first appear in the throat, but is not so often seen in this loca- 
tion as is the efflorescence of scarlet fever or measles. It is possible that 
the efflorescence always appears first in the throat, but that in many cases 
it is not seen early enough to be recognized, as the manifestations are very 
evanescent. 

This efflorescence of varicella is almost the only one which is character- 
istic of a specific disease. By this I mean that while a vesicle does not 
necessarily allow us to diagnosticate any disease of the skin, yet when these 
vesicles with their areolae, in combination with constitutional symptoms, 
appear in groups in different parts of the body, there is no other disease 
with which we should be likely to confound it, with the exception of variola, 
vaccinia, and possibly herpes zoster. 

The course of varicella is rapid. It is characterized by a sudden onset 
of constitutional symptoms, with the almost immediate appearance of the 
efflorescence. The efflorescence runs a rapid course, appearing quickly on 
different parts of the skin, and disappearing almost as quickly as it appears. 
The disease lasts about a week or ten days, and, as a rule, has no serious 
sequelae. It is rarely complicated by any other disease. 

Complications. — During the course of certain epidemics, however, it 
has been noticed that the kidney is affected. This complication usually 
occurs after the efflorescence has almost disappeared, and in the second week 
from the time of the beginning of the attack. In these cases albuminuria 
is present, and in all probability is caused by some form of nephritis, 
although nothing definite is known about this class of cases. 

Gangrenous Varicella. — A complication which at times arises in 
varicella is what is called the gangrenous form of varicella, the pathology 
of which I have already described. Although it is most common in ill- 
nourished children, yet it does not necessarily attack this class of cases, and 
it seems to have some connection with the gangrenous processes which certain 
individuals show a tendency to develop. 

Prognosis. — The prognosis of varicella is usually, unless the above- 
mentioned complications arise, extremely favorable. Cases occur where the 
prognosis is rendered unfavorable by lack of proper care during the conva- 
lescence, resulting in broncho-pneumonia and other diseases. In some cases 



THE EXANTHEMATA. 



527 



the prognosis is rendered unfavorable by the anaemia which is apt to follow 
an attack of varicella^ and is at times pronounced. 

Diagnosis. — The diagnosis of varicella is not difficult if we bear in 
mind the characteristics of the diseases which it is most apt to simulate. 

In differentiating it from variola we must consider the great difference 
in the rapidity of the development of the efflorescence in the two diseases. 
In variola it is essentially slow, in varicella it is characteristically quick. 
The papules of variola are hard to the touch, those of varicella are soft. 
The vesicle of variola, as a rule, is umbilicated and soon becomes a pustule ; 
these characteristics are absent in varicella. The whole com^se of variola 
occupies a period of from two to three weeks ; the course of varicella is 
much shorter, and is often limited to one week. Finally, the severe con- 
stitutional symptoms and the long prodromal stage in variola differ essen- 
tially from the lack of prodromata and the mild constitutional symptoms in 
varicella. 

In vaccinia the slow progression of the lesions from papules to pustules, 
and the rather limited areas affected, serve to distinguish it from the succes- 
sive crops of vesicles, with their rapid development and extensive areas, 
which are met with in varicella. 

The differential diagnosis of varicella from herpes zoster is not difficult, 
if we consider that the vesicular efflorescence in herpes zoster follows the 
course of some set of nerves, while that of varicella is perfectly irregular 
and is in no way connected with the distribution of the nerves. 

In this table (Table 93) I have arranged the chief points of difference 
between varicella and variola : 



Incubation . 
Prodromata . 

Efflorescence . 



Desquamation 
Duration . . 
Type .... 
Temperature . 



TABLE 93. 

Varicella. 
Two to three weeks. 
None or slight. 

On the skin. Eapidly becomes 
vesicular. Not umbilicated. 
Unilocular. Irregular. Nu- 
merous. Universally distrib- 
uted in successive crops. Vesi- 
cles differ greatly in size On 
pricking, collapses entirely. 



Slight crust formation. 

Short, one week to ten days. 

Mild. 

Irregular, not high. 



Variola. 

One to two weeks. 

Three to four days in length. 
Active. Severe. 

Under the skin, A slow progres- 
sive development from a mac- 
ule to a papule, from a papule 
to an umbilicated vesicle, then 
to a pustule, Multilocular. 
Regular. Not numerous. De- 
fined in its localization. Le- 
sions, as a rule, of uniform 
size. On pricking, collapses 
partially. 

Pronounced crust formation. 

Long, three to four weeks. 

Severe. 

Eises suddenly. Remains high 
until papules are developed, 
when it falls considerably. 
Rises again during the develop- 
ment of the pustules. 



528 PEDIATRICS. 

1 have here a boy (Case 229) who was brought to the hospital a few hours ago, and 
who illustrates very well what I have told you concerning the efflorescence of varicella as 
it occurs in the throat. 

He is said to have been well until yesterday, when towards evening he began to feel 
feverish, to have loss of appetite, and to complain of sore throat. He was brought to the 
hospital to be treated for a supposed cold. On examination nothing abnormal was found 
except these lesions which I shall show you in the throat, and a few vesicles behind his ears 
and on his back. These lesions on the skin have appeared since he came to the hospital, 
subsequent to those which were seen in his throat a few hours ago. On making the child 
open his mouth and depressing his tongue you will see certain lesions of the mucous mem- 
brane of the entire throat (Plate VIII., Varicella, facing page 781). The tongue, you see, 
is very slightly coated. The tonsils are not enlarged. The mucous membrane of the hard 
and of the soft palate and of the pharynx is slightly hypersemic. On the upper and right 
side of the hard palate and very near where it joins the soft palate you will notice two small 
vesicles surrounded by a distinct red areola. To the left and below these lesions are three 
minute macules, two of which have almost become papules. You must remember that the 
difference between a vesicle and a pustule is simply one of degree. On the skin behind the 
ear and on the back you will notice that these lesions are purely vesicular. There are not 
so many leucocytes in the vesicles on the skin as are evidently present in the two lesions 
on the hard palate, which give the latter a yellowish color in contradistinction to the 
pearly white color of the dermal lesions. 

This case illustrates very well the importance of making a thorough examination of 
the throat in children, which I have referred to in a previous lecture (Lecture XIII., page 
323) , for unless the throat had been examined the child would have been supposed to have 
a cold and would have been allowed to remain in the clinic and thus spread the contagium. 

To illustrate still further the efflorescence of varicella, I happen to 
have in the isolating ward of the Children's Hospital a case in which the 
varicella is at its height and has been running its course for two days. 

This child (Case 230, Plate VI., Varicella, facing page 504), a girl, was attacked with 
headache and malaise three days ago in the morning. In the afternoon an examination 
showed an efflorescence in the throat, but there was also a well-marked vesicular efflores- 
cence on the back. This efflorescence soon began to come out in crops in diflerent parts 
of the body, on the limbs, behind the ears, and on the scalp. There are also a few lesions 
on the face. Here on the back you will notice a number of lesions, some of which are 
simply macules, and again a few of the macules have become papules. In most cases, 
however, the lesions are distinctly vesicular, varying in their contents to such a degree that 
we sometimes see the pearly white appearance and again the yellowish color of a vesicle 
which has become somewhat pustular. In other places the vesicles have broken down 
and little crusts have formed in their centres, which are somewhat indented. On pricking 
one of these vesicles you see that it collapses and is emptied of its entire contents, showing 
that it is unilocular. The vesicle of variola when pricked in this way would in most cases 
be only partially emptied, showing that it was multilocular. 

In this next bed is a little girl (Case 231) who shows the lesions of varicella in all these 
stages. 

This child was brought from the surgical ward three days ago, and, as you see, was 
being treated with plaster-of-Paris bandages. The efflorescence, chiefly vesicular in charac- 
ter, first appeared behind the ears, and one or two of these lesions which have mostly run 
their course and have become crusts are, as you see, still present. The whole of the child's 
back is thickly covered with the efflorescence. The lesions are also on the arms, legs, and 
abdomen, and, although not so numerous on the front of the chest as on the back, they are 
very prominent in this area. The lesions have attacked the chin, lips, face, nose, and 
forehead, and can also be found on the scalp. 

I shall order the plaster bandage to be removed, as a fixed bandage should never be 



THE EXANTHEMATA. 



529 



used during the course of any of the eruptive diseases, owing to the probability that exten- 
sive ulcerations will develop under them. 

Case 231. 






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Varicella. Stage of efflorescence, third day. 



The temperature in varicella is in most cases not high, and is very 
irregular. It usually rises when a crop of lesions of any considerable 
number develops, and falls again at the outbreak. This chart (Chart 12) 









CH 


[A] 


^T 


12 












Dai/s of Disease 




F 

107° 
106° 
105° 
104° 
103° 
102° 
101° 
100° 
99° 

NORMt 
TEMP. 

98° 
97° 
96° 
95° 


1 


2 3 


4 


5 


6 


7 


8 


9 


10 


c 

41.6° 
41.1° 
40.5° 

40.0° 

39.4° 

38.8° 

38.3° 

37.7° 

37.2° 
37.0° 
36 6° 

36.1° 

35.5° 

35.0° 


M E 


HEM 


E 4 E 


H E 


M E 


tf E 


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Varicella simplex. 
3-4 



530 



PEDIATRICS. 



shows the usual variations which you may expect to find in the temperature 
of varicella. 

I have also here a child (Case 232), three years of age, who was brought to the hospital 
with Pott's disease, and with a paraplegia arising from a transverse myelitis caused by the 
disease. Nothing abnormal was found in connection with the lungs, heart, or kidneys. 
Until the child was attacked with varicella the temperature was usually normal, but some- 
times rose to 37.7° C. (100° F.), and occasionally as high as 38.3° C. (101° F.). 

About one month ago the child became restless, and his temperature rose somewhat. 
On the following day the symptoms became more marked, and the temperature was found 
in the evening to be 39.4° C. (103° F.). On this day an eflaorescence of varicella appeared 
on his skin. During the third day of his sickness his face swelled, and in the evening his 
temperature was found to be 41.1° C. (106° F.). The vesicular efflorescence was well 
developed on his trunk and face by this time. Somewhat later it became universal and 
assumed a purulent character, especially about the face. During the fourth, fifth, and sixth 
days of the disease his temperature varied in the evening from 39° C. (102.2° F.) to 39.4° 
C. (103° F.). On the seventh day of the disease all the symptoms increased in severity, 
and the temperature was found to be 41.1° C. (106° F.). On this day some of the vesicles 
on the face had become ulcers. Nothing abnormal was found in the lungs, and no albumin 
or casts in the urine. A psoas abscess developed during the progress of the varicella. The 
ulcers on the face, as you see, have extended to such a degree that the child has lost the 
sight of one of its eyes. The child is sinking rapidly. The treatment, which has been 
essentially with stimulants, has failed to keep up its strength, and the local treatment in 
connection with the eye has proved entirely unsuccessful. 

This child represents a case of gangrenous varicella. 



Here is the temperature chart (Chart 13) of the case. 

CHAET 13. 





Daj/s of Dis^cLse 




F 












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2 


3 


4 


Jh 


6 


7 


8 


9 


10 


It 


12 


13 


14 


15 


c 


107° 
106° 
105° 
104° 
103° 
102° 
101° 
100° 
99° 

fJOBML 
tEMP 

98° 

97° 

, 96° 

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M E 


ME 


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M E 


M E 


M E 


M E 


M E 


ME 


M E 


M £ 


41.6° 

41. |o 

40.5° 

40.0<» 

39.4° 

38.8° 

38.3° 

37.7° 

37.2° 
37.0° 
36 6°. 

36.1° 

35.5? 

35.0° 












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T. -. : =7T— rrrr tttt- 



Varicella gangrsenosa. 

(Subsequent history of the case.) The child continued to grow weaker, and died on the 
thirtieth day from the time when the first symptoms of the varicella were noticed. No 
autopsy was obtained. 



THE EXANTHEMATA. 531 

Treatment. — The treatment of varicella is simply symptomatic. The 
child should stay in the house, and its room should be kept at an even tem- 
perature. The diet should be milk. The child should be carefully watched 
to prevent it from scratching, as lesions deep enough to produce scars may 
often be obviated in this way. This treatment should be continued imtil 
all the constitutional symptoms have passed away and the efflorescence has 
disappeared. Complete isolation should, if possible, be enforced, as, although 
the disease is usually insignificant, we can never in the beginning determine 
whether or not a rare and severe case is about to develop. 

These rules for treatment are precautionary, and are based on the suppo- 
sition that a child who has had a constitutional disease of this nature must 
be more sensitive to exposure of various kinds. As it is possible in some 
cases for the kidney to be affected in the later stages of the disease, just as 
it is in scarlet fever, it is well to guard against this complication by the 
protection of the skin from changes of temperature and by the use of milk 
as a diet. In a considerable number of cases, especially in young children, 
an anaemia of greater or less degree results from the disturbance of nutrition 
which so often accompanies the disease. In these cases the administration of 
saccharated carbonate of iron or of tartrate of iron and potash is indicated. 



532 PEDIATRICS. 



IvKCTTURK XXV. 

THE EXANTHEMATA.— (Continued.) 

Scarlet Fever, 

The third member of the group of exanthemata which I shall speak of 
is scarlet fever^ and I have brought you to the scarlet fever ward of the 
Boston City Hospital to-day to show you some illustrative cases of this 
disease. 

Scarlet fever is an acute infectious disease, characterized by a short 
incubation, short prodromal stage, erythematous efflorescence, pronomiced 
desquamation, and long course. The micro-organism which produces it 
has not yet been determined. With the exception of variola, it is the 
most dangerous of the group. As it occurs so much more frequently in 
early life than variola, on account of its not being preventable by inoculation, 
it is to the physician the most important of all the exanthemata. 

The complications of scarlet fever are so much more serious and its 
sequelse so much more common and grave than those of varicella and 
measles, that its immediate diagnosis and prompt treatment are of vital 
necessity in every community where numbers of children are liable to be 
attacked by the disease. It should, therefore, receive the most careful study 
of every physician whose practice is among children. 

Scarlet fever is the most irregular of all the exanthemata in its virulence 
and in the manifestations which it presents in different individuals. It 
is usually epidemic, returning to the same localities after a period of years. 
It is at times sporadic, and is commonly endemic in large cities. That the 
epidemics of scarlet fever vary in severity has been clearly shown a number 
of times, so that we cannot ascribe the virulence of the disease in certain 
years to individual susceptibility. The sporadic cases may be of the most 
malignant or of the mildest type. A mild case may give rise to a malignant 
case in another child, and a malignant case may give rise to a mild one. 
The epidemics of scarlet fever spread slowly, in contradistinction to those of 
measles, which spread rapidly. Scarlet fever may occur more than once in 
the same individual, but this is rare. Instances have occurred where a child 
has had scarlet fever, and, on returning after several weeks to the same 
room, even after it had been disinfected, has again contracted the disease in 
its typical form. The source and identity of the contagium have not been 
definitely determined, but the skin appears to be its chief vehicle. This con- 
tagium has a wonderful tenacity for clothing and other articles, and may be 
capable of reproducing the disease for many months. 

In reference to what I have just said concerning the slow spread of 



THE EXANTHEMATA. 533 

scarlet fever during epidemics in comparison with the rapid spread of 
measles, certain clinical facts are significant. The disease does not seem to 
be very infectious in its early stages. AYe are thus led to believe that it 
is during the stage of desquamation that the contagimn is most likely to be 
dissemuiated. Measles, on the other hand, is known to be highly infectious 
in its early stages, and for this reason to spread more quickly. 

As the description of actual cases aids the student to remember im- 
portant points in a disease, I shall in a few words tell you about two 
children w^ho have been under my care, in order to show you the difference 
between scarlet fever and measles as regards the stage in w^hich they are 
most likely to be infectious and the means by which their contagium is 
usually conveyed. Notice, how^ever, that I say usually, for the contagium 
of both diseases may be active through their w^hole course. 

A boy (Case 233) six years old and a girl (Case 234) four years old slept in the same 
room, with their beds touching each other. The boy was taken sick May 1, but remained 
in the same room with his sister during that day and the following night. He was seen by 
me early on the morning of May 3, and was then found to have scarlet fever. His sister was 
taken to the country, and the boy was left in charge of a trained nurse. There was absolutely 
no communication between the town-house and the country-house, either by people, clothes, 
or letter. I myself did not again see the boy during his sickness, having placed him under 
the charge of another physician. 

On June 1 1 was called to see the girl, and found that she had scarlet fever. There were 
no other cases of scarlet fever in the vicinity of the country-house where she had remained 
since leaving the city. 

The boy at this time was desquamating freely, and four days previous to the girl's being 
taken sick a letter written by him had been sent to her, and she, after having had it read to 
her, had been allowed to keep it under her pillow. 

A careful study of this case led to but one conclusion, — that the boy during the period 
of his desquamation had infected his sister at a distance of twenty miles by enclosing the 
contagium of scarlet fever in an envelope. The girl, although she had been in the same 
room with the boy for thirty-six hours at the beginning of the disease, and although suscep- 
tible to the disease, had not contracted it at that time, owing to its very slightly infectious 
nature in its early stages. On the other hand, the incubative stage of scarlet fever being 
only a few days, and many instances having proved that the disease is very infectious during 
its period of desquamation, it was evident that the girl had been infected by means of the 
letter. 

In the following year, on May 20, I was again called to see the same boy. He had been 
well in the morning, but in the afternoon was found to have a high pulse and temperature, 
with coryza and lachrymation, so that it was deemed best to send the sister, who had been 
in the nurser}^ only a few hours with her brother after he had been taken sick, to another 
house, while the boy was absolutely isolated. Three days later the boy was found to have 
measles. Ten days later the girl was attacked by measles. This case merely emphasizes 
the now commonly accepted belief that measles, in contradistinction to scarlet fever, is 
highly infectious in the early hours of the disease. 

Whether the contagium of scarlet fever can be carried by the breath is, 
I think, somewhat doubtful. 

There are, how^ever, cases w^hich lead me to believe that scarlet fever may 
be transmitted at a very early stage of the disease. An instance illustrative 
of this came to my notice not long ago : 



634 PEDIATRICS. 

A child (Case 235) who had contracted scarlet fever a few days previously came to a 
party given in a small and practically isolated community. At this time the child was 
beginning to- feel sick and complained of a sore throat. A spoon which had been used by 
her was also used, before it was washed, by one of the other children. Six or seven days later 
this second child (Case 236) was attacked by scarlet fever. 

A careful and critical investigation of the possible origin of the second case resulted in 
the evidence strongly pointing towards a direct transmission of the contagium from the 
mouth of one child to that of the other by the use of the spoon. 

Scarlet fever may occur at all ages, but is rare during the first year of 
life. It has been met with in young infants who were nursing, and who 
have proved to be the focus of infection for a whole household. 

It may occur in animals, and the infection may be transmitted by animals, 
such as dogs and cats, by milk, and by clothing. 

There is no known prophylactic against scarlet fever except isolation, 
which for many reasons should be rigorously enforced. We must remember 
the fact that when the child has passed its tenth year the chances of its ever 
contracting the disease are very much lessened. We must also appreciate 
that it is especially important to protect children who are learning, or who 
have just learned, to talk. The commonly occurring and often intractable 
form of otitis which accompanies scarlet fever may not only render the child 
deaf, but in a case where the child has not learned to talk it may lead to 
deaf-mutism. We should, therefore, under all circumstances discountenance 
the opinion so often expressed by the laity, and sometimes even by physi- 
cians, that it is well for children to have these diseases while they are young, 
on the ground that otherwise they will probably contract them at a later 
period of life, when the type of the disease may be more severe. The 
assertion that the type of the disease is more severe in adults than in 
children is not corroborated by my experience. 

Pathology. — The organs primarily affected in scarlet fever are the 
skin and the throat The principal complications which arise in the course 
of the disease are connected with the ear and the cervical glands. The chief 
sequela, and the only one which is at all common, is nephritis. Cardiac 
disease, commonly secondary to the nephritis, may occur. 

Lesions of the other organs are somewhat unusual and have no definite 
connection with the scarlet fever. They are generally due partly to the 
fever and partly to the septic processes which have arisen in the course of 
the disease, and are represented, as would naturally be expected, by a con- 
gested condition of the various internal organs, and by the usual changes 
which are found in pleuritis, pericarditis, endocarditis, and meningitis. 

Skin. — Macroscopically the morbid conditions of the skin in scarlet 
fever, though varying in their manifestations, are usually represented by an 
intense general erythema covered thickly with minute macules, which are of 
a darker red than the accompanying hypersemia. Minute white spots may 
also appear thickly scattered over the reddened surface, probably arising 
from areas of unaffected skin existing in the midst of the general hyper- 
semia. An appearance like that of milium is also at times noticed to be 



THE EXANTHEMATA. 535 

scattered on the areas of skin affected by the erythema. Ko evidence of 
this hypersemic condition, which is so pronounced during life, is found after 
death. 

According to IN'eumann, microscopic examinations of the skin by means 
of hardened sections of specimens from cases of scarlet fever and measles in 
the stage of desquamation explain in a measure why the former is so much 
more likely to be infectious during its stage of desquamation than is the 
latter. In contradistinction to the pathological processes which are found 
in the skin in measles, and which affect chiefly the blood-vessels and glands, 
a very different picture is presented on examination of sections of skin 
taken from scarlet fever. In the latter w^e find the pathological process 
represented especially by exudative cells, which are very numerous and 
closely packed together, reaching even up to the horny layer of the epidermis. 
Occasionally these exudative cells may finally take the place of the epi- 
dermal cells, appearing on the free surface of the skin, and are gathered 
thickly among the excretory ducts of the cutaneous follicles. You will thus 
readily understand why the tissue proper of the skin and its epidermis 
present no marked changes in measles, and why the epidermal cells are far 
less likely to carry the contagium than in scarlet fever, where the possibility 
of contagium exists until the desquamation has entirely ceased. 

Throat. — The earliest lesions of scarlet fever appear on the mucous 
membrane of the hard and the soft palate. This appearance is very similar 
to the efflorescence which is seen on the skin, except that the minute white 
spots do not appear on the congested mucous membrane. The pathological 
conditions which occur in the throat in scarlet fever may either be simply 
catarrhal, or result in one of the more severe inflammatory conditions affect- 
ing the tonsils, the pharynx, and the larynx. 

As is stated by Delafield and Prudden, one of the most marked features 
of scarlet fever is the predisposition which it entails to the incursion of 
pathogenic germs other than those which we believe to cause this disease. 
Thus, in addition to the inflammatory lesions produced by the scarlet fever 
organism an acute exudative inflammation of the mucous membrane may 
occur, and may be associated with them. This is apparently caused by the 
growth of a streptococcus which, according to Welch, in morphological and 
biological character seems to be identical with the streptococcus pyogenes. 
In these cases there may be much or little fibrinous exudate, and there may 
in the early stages, or even through the whole course of the affection, be 
none at all. The pellicle when formed may be more or less adherent, and 
sharply circumscribed, or it may tend to spread. The submucous tissue 
may show little change, or much congestion and oedema, or it may be the 
seat of suppurative inflammation. The entire process may be confined to 
the tonsils. While under these varying conditions the inflammatory process 
is usually a local one and runs its course, with or without the symptoms of 
septicaemia, occasionally the streptococcus finds access to the blood and may 
induce the lesions of pyaemia. On the other hand, it may by inhalation 



536 PEDIATKICS. 

gain access to the lungs and induce varying phases of complicating broncho- 
pneumonia. The staphylococcus pyogenes is not infrequently associated 
with the streptococcus in these lesions, but it is not apparently of prominent 
significance. Simulating very closely as it does in many cases both the 
local and the general phenomena of diphtheria, this pseudo-membranous 
condition was formerly confounded with it, but it is now recognized as a 
distinct disease. 

There have been a number of extended investigations made on what are 
called the pseudo-membranous inflammations of the throat in scarlet fever. 
Booker has reported eleven cases of pseudo-membranous angina (two fatal) 
complicating scarlet fever, and one case of simple angina without exanthem 
in a family three members of which had scarlatina. In all these cases, 
as well as in four scarlatinal anginas without pseudo-membranes, Booker 
found streptococci as the predominant organism, and in none was the Loeffler 
bacillus present. The staphylococcus aureus was found in eleven cases 
without apparent influence on the severity of the disease. No difference 
was observed between the early and the late pseudo-membranous anginas as 
regarded the bacteria present. Booker describes with much detail the mor- 
phological and bacteriological characteristics of the streptococci found, and 
divides them into groups. 

Park, in a series of one hundred and fifty-nine cases, reports nineteen 
cases of pseudo-membranous inflammation of the throat complicating scarlet 
fever. In seventeen of these cases streptococci predominated, and in only 
two was the Loeffler bacillus present. Staphylococci were found in only a 
few cases. Williams has also reported cases of this kind, and Morse has 
reported ninety-nine cases of pseudo-membranous inflammation of the throat 
complicating scarlet fever. The Loeffler bacillus was found in twenty-three, 
with a mortality of forty-three per cent., and was not found in seventy-six, 
with a mortality of twenty-one per cent. 

Finally, we may conclude that in scarlet fever the mucous membrane of 
the throat is rendered peculiarly vulnerable to the invasion of pathogenic 
germs. Where the morbid condition in the throat is represented by a 
pseudo-membrane it will be found that in the great majority of cases the 
process, as stated by Welch, is due to streptococci ; but where diphtheria is 
prevalent and the opportunities are favorable for exposure, a large portion 
of the pseudo-membranous cases may be due to the Klebs-Loeffler bacillus. 

In addition to the lesions of the throat just described, the micro- 
organism of scarlet fever may attack the naso-pharynx. In this way, also 
by direct extension through the Eustachian tubes, secondary aural lesions 
may be produced. The morbid changes in the mucous membrane of the 
naso-pharynx which thus take place may result in a thickening of the 
tissues, which in some cases lasts for many months after the scarlet fever has 
run its course. 

Bar. — The pathological condition of the ear which is most commonly 
met with in scarlet fever is an acute inflammation of the middle ear. This 



THE EXANTHEMATA. 537 

mflammation is likely to result in destruction of tissue, the formation of 
adhesions, the establishment of a long-continued suppurative process, and 
an accompanying necrosis. 

Cervical Glands. — There may be hyperplasia of the cervical lymph 
nodes. This condition is sometimes accompanied by inflammatory oedema 
of the tissues of the neck, which may go on to suppuration and even to 
gangrene. In these cases streptococci are found in the glands and in the 
areas of suppuration. The infection is supposed to originate in the tliroat. 
The enlarged glands are, as a rule, indicative of secondary or mixed in- 
fection, though it is possible that the slighter forms of enlargement may 
be due to reflex irritation with resulting hyperplasia from the scarlet fever 
contagium. In the severe form the glands are at times very much enlarged, 
and where a gangrenous process results the blood-vessels may be afiected to 
such an extent as to be ruptured. 

Kidney. — In scarlet fever, as in a number of other infectious diseases, 
there are certain poisons produced in the course of the disease which are 
probably soluble in character. The results of bacteriological cultures in 
scarlet fever have shown that in a number of cases there is a general strep- 
tococcus infection, the infection probably coming from the lesions in the 
pharynx. In these cases of general infection streptococci may be cultivated 
from most of the organs of the body, there being a general septicaemia. In 
a number of these cases extensive lesions may be found in the kidneys, and 
yet these lesions may bear no relation whatever to the presence or absence 
of streptococci. In like manner, streptococci may be found in the kidney 
without any lesion of the kidney. These lesions are difliise, and aflect both 
kidneys and all parts of the kidney. From the best evidence which we 
have it would seem that the virus, or whatever it is which produces the 
lesions in the kidney, is not a living organism, but is a soluble chemical 
poison produced by the organisms of scarlet fever, or by other organisms, 
located in some other part of the body. This soluble poison when produced 
elsewhere is taken locally into the blood and affects various parts of the 
economy. In post-mortem examinations of scarlet fever certain lesions 
will be usually found in the kidneys. 

These lesions, according to Councilman, may be divided into two classes, 
(1) represented by simple degeneration of the epithelium, and (2) represented 
by marked changes in the tissues of the kidney. 

In the first class of cases the soluble poison may only affect the integrity 
of the capsular epithelial cells of the glomeruli. The poison may produce 
certain degenerative changes in these, but need not be accompanied by any 
proliferation of cells, or by any condition which would be characterized as 
inflammatory. It is more than probable that these simple degenerative 
lesions are accompanied during life by evidence of albuminuria, and in 
case death takes place there may be no macroscopic evidence of any lesions 
in the kidneys. Careful microscopic examination, however, will slunv a 
condition of degeneration in the capsular epithelium of the glomeruli. 



538 PEDIATRICS. 

Associated with this there will usually be found cloudy swelling of various 
degrees of intensity in the cells of the convoluted and the smaller collecting 
tubules. The degeneration here is rarely of a fatty character. Clinically, 
in the purely degenerative changes there may be only albuminuria with the 
presence of faint hyaline casts, and here and there a few leucocytes. 

In the second class, owing to a greater intensity in the action of the 
poison, or to some possible difference in its character, more marked changes 
may take place in the kidney, and may be accompanied by the degenerative 
lesions which are distinctive of the first class. Different forms of lesions 
may occur in the second class, and, according to the predominance of one 
form over the other, may characterize a special form of renal disease. 
These lesions may be divided according to their anatomical distribution into 
interstitial, where there is a marked proliferation of the interstitial tissue 
of the kidney, and glomerular, where the lesions are chiefly confined to the 
glomerulus and its capsule. 

In the interstitial form there will be found in the interstitial tissue be- 
tween the tubules accumulations of cells, which are probably due to a pro- 
liferation of the cells of the capsule and of the connective tissue. These 
cells, or most of them, are epithelioid in character, and show very few leuco- 
cytes mingled with them. This form of nephritis should be considered as 
purely interstitial, since its lesions are in no way related to those of the 
epithelial tissue. There is both a general and a focal infiltration of cells in 
the interstitial tissue. The focal infiltration is found principally in the 
cortex of the kidney and about the glomeruli, the glomerulus frequently 
appearing as a centre from which the infiltration extends into the interstitial 
tissue between it and the surrounding tubules. 

This form of nephritis was first described by Wagner as the lymph- 
oid kidney. The kidney, macroscopically, is swollen ; the capsule is easily 
stripped from the cortex, and is moist, whitish, and opaque. Usually there 
is no evidence of hemorrhage, although in some cases points of punctiform 
hemorrhage may be found in the cortex and in the intermediate zone. 

Clinically, in this form there may be little evidence of the severity of 
the lesions. There may be, however, albuminuria corresponding to what 
is seen in the purely degenerative class. The quantity of the urin^ may 
be very little diminished, and casts may be present, as well as a certain 
number of desquamative epithelial cells and leucocytes. 

These lesions are not confined to scarlet fever, but may be foimd in 
diphtheria, in measles, and in other infectious diseases of children, but they 
are not common in the infectious diseases of adults. 

This microscopic section, made by Councilman (Fig. 90, page 539), repre- 
sents a good example of these interstitial lesions in scarlatinal nephritis. 

This section was taken from a case of pure scarlet fever. There was 
no anuria and no dropsy. The kidneys were enlarged, whitish, and with- 
out hemorrhage. Cultures from this case gave a general infection with 
streptococci in all the organs except the kidney, and I wish you to notice 



THE EXANTHEMATA. 



539 



especially that the kidneys, notwithstanding the extent of their lesions, 
were found to be free from streptococci. The epithelium of the tubules is 
somewhat swollen. The tubules themselves are slightly dilated, and the 
epithelium is more granular than normal. The interstitial tissue is much 
more extensive than normal. The spaces between the tubules are increased 
both by oedema and by cellular infiltration. In the interstitial tissue you 
will see blood-vessels filled with cells of the same character as those outside. 
It is probable that most of the cells outside come from proliferation of the 
cells of the blood-vessels. The round spaces in the interstitial tissue repre- 
sent blood-vessels. 

Fig 90 



--r-ri^'S 

















Interstitial nephritis. Section of kidney from child with scarlet fever. (Hartnack, ocular No. n., 
objective Xo. YUl. Tube closed.) 

The other form of nephritis, called the glomerular (page 540), is much 
more frequently found in scarlet fever than the interstitial form, and may 
be considered as almost typical of the disease. In this glomerular form 
the chief lesion of the disease consists essentially in a proliferation of the 
capsular epithelium combined with hyperplasia of the connective tissue. 

The proliferation of the capsular epithelium leads to the formation of 
masses of cells within the capsule between the glomerular capillaries and 
the capsule. These cells evidently result from the proliferation of the 
capsular epithelium. As a result of this there may be greatly increased 
pressure on the vessels of the glomerulus, with possibly obliteration of these 
vessels. The cellular infiltration in the interstitial tissue is not so extensive 
as in the other form (Fig. 90). Accompanying these changes in the 
glomerulus there is almost always more or less hemorrhage both in the 
tubules and in the interstitial tissue. 



540 



PEDIATRICS. 



Here is a section, made by Councilman (Fig. 91), of glomerular nephritis. 

This section was taken from a case of scarlet fever complicated by 
glomerulo-nephritis. In the centre of the field a glomerulus is seen, with an 
infiltration of cells in the capsular space. The capsular cells are oval and 
distinctly epithelioid in character. Cellular proliferation of the cells having 

Fig. 91. 




Capsular glomerulo-nephritis. Section of kidney from child with scarlet fever. (Hartnack, 
ocular No. II., objective No. VIII. Tube closed.) 



generally the character of those in the section of interstitial nephritis (Fig. 
90) is found, as you see, in the interstitial tissue. In the tubule at the left 
upper corner there is hemorrhage, and hemorrhage is found in the interstitial 
tissue on the right of the specimen. In this case the anuria and dropsy were 
extreme. 

This form of nephritis may be best designated as capsular glomerulo- 
nephritis. The kidney is swollen and much more hypersemic than in the 
interstitial form. The markings of the cortex either are obscured or cannot 
be made out at all, and there are numerous areas of hemorrhage and 
hypersemia, giving the kidney a mottled appearance. 

It is this capsular glomerulo-nephritis which gives, the most marked 
clinical evidence of the extent of the lesions in the kidney. In this form 
dropsy is almost always present, the amount of urine is greatly diminished, 
and in the more severe cases there may be complete anuria. Blood-casts 
are found more frequently in the urine than in the interstitial form. The 



THE EXANTHEMATA. 541 

diminution in the amount of the urine points to involvement of the glomeru- 
lus. Even severe cases of this form may be recovered from. The process 
of cell-proliferation may cease, the cells formed in the capsular space may 
disappear and pass out, and the kidney in after-years may show few or no 
evidences of the process through which it has passed. In a certain number of 
cases, however, from this form of nephritis a chronic nephritis is developed. 
Cases of this kind have been reported, notably one by Aufrecht. 

In both the interstitial and the capsular glomerulo-nephritis fatty degen- 
eration of the epithelium is not found to any degree. The epithelium is 
frequently swollen and granular, and may be hyaline. 

These two forms of nephritis should be separated from each other, 
although transitions between their lesions are found. Usually they can be 
distinguished macroscopically. 

We can, therefore, recognize three pathological conditions of the kidney 
in scarlet fever : first, the purely degenerative ; second, the acute interstitial ; 
and third, the capsular glomerular. 

Heart. — The pathological conditions of the heart which are at times 
found in scarlet fever do not differ in their macroscopic appearances from 
those met with in other diseases. Cardiac disease occurring in the course of 
scarlet fever may arise in two ways : (1) from the general septic condition 
existing during the period of the height of the temperature and general 
efflorescence, and represented usually by an endocarditis ; (2) at a much 
later period from a nephritis which has arisen as a complication, and fol- 
lowing which, from the resulting increased blood-pressure, enlargement of 
the heart has been produced, which may be represented by hypertrophy or 
by dilatation, or by both. 

In connection with this subject, Silbermann has found on examining a 
large number of cases of nephritis during attacks of scarlet fever a decided 
hypertrophy of the heart combined with dilatation. In some cases both 
sides of the heart were equally affected, but usually only the left side was 
involved. In only a few cases was there found a partial fatty degeneration 
of the muscular fibres ; the endocardium, pericardium, and blood-vessels 
were normal. According to Silbermann's observations, the cardiac affection 
was related to the post-scarlatinal nephritis, and not to the scarlet fever 
process itself, as the hypertrophy was never found where the child died in 
the early weeks of the scarlet fever. He calls attention to the short period 
which intervened between the first appearance of the nephritis and the con- 
secutive heart hypertrophy, in many cases the time not being much longer 
than a week. He also noticed that in the cases where hypertrophy and 
quick dilatation followed the acute nephritis of scarlet fever the ages of the 
children were three and a half, four, five, and six years, this post-scarlatinal 
cardiac enlargement thus corresponding to the physiological hypertrophy 
which I have referred to in an earlier lecture (Lecture IV., page 123). 

Scarlet fever may be divided into (1) the benign form and (2) the 
malignant form. 



542 PEDIATRICS. 

I have already referred to the variations in type of cases of scarlet fever. 
The difference in the symptoms of the common, or benign, form of the 
disease from those of the rare, or malignant, form is very striking. They 
could well be classified as entirely separate diseases, were it not that the 
contagium has been proved to be the same in each, by the fact that one form 
of the disease may give rise to the other in different individuals. It seems 
as though it were more the susceptibility of the individual to the scarlet 
fever contagium than the contagium itself which produces a greater or less 
severity of the symptoms. I shall first speak of the benign class of cases, 
such as you see here in my scarlet fever ward, as it is this class which you 
will be more likely to meet with in your practice. These cases, as you will 
see, either run a simple typical course or are accompanied by variations 
and complications which make their course irregular. The simple typical 
case of the benign form of scarlet fever is such as I have already described, 
and is characterized by its sudden onset and long duration. 

Incubation. — The stage of incubation of scarlet fever is uncertain and 
irregular, but, as a rule, it is shorter than that of any of the other ex- 
anthemata. It is usually less than seven days, and quite frequently it is 
only from two to four days. 

Symptoms. — Prodromata. — The invasion of the disease is usually 
sudden and, as a rule, active. The child feels very sick, looks dull, com- 
plains of sore throat and nausea, and in a large number of cases vomits 
continuously. The pulse is rapid. The temperature is high, — 39.4°, 40°, 
40.5° C. (103°, 104°, 105° F.). In infants and very young children if 
the temperature rises to 40° or 41.1° C. (104° or 106° F.) convulsions are 
very likely to occur. The higher the temperature at the beginning of the 
disease the more active the symptoms, and the shorter the prodromal period 
the more severe will be the case. An initial temperature of 40° C. (104° 
F.) points towards a severe case. 

Young children seem to show a less sensitive condition of the throat than 
is met with in older children and in adults. The appearance of the mucous 
membrane of the throat, although perhaps not characteristic, as at times a 
simple non-infectious pharyngitis may simulate it quite closely, is, in con- 
nection with the general symptoms, at least suggestive. The mucous mem- 
brane of the hard and the soft palate and of the pharynx is much con- 
gested. On the hard and the soft palate thickly scattered over the reddened 
surface are minute macules the color of which is a little darker red than that 
of the intervening mucous membrane. This condition represents the earliest 
stage of the efflorescence which later appears on the skin. 

The length of the prodromal stage varies, as a rule, from twelve to thirty- 
six hours. During this stage the temperature continues to rise somewhat, 
and at its end the efflorescence appears on the skin. 

Efflorescence. — The efflorescence of scarlet fever is of an erythematous 
and punctate character, sometimes looking as though minute macules had 
been sprinkled over the general redness of the skin. It starts on the front 



THE EXANTHEMATA. 



543 



of the neck and the upper part of the chest, and rapidly extends all over the 
body and extremities, and upward to the face. This characteristic order of 
invasion of the skin aids us in distinguishing the ef&orescence of scarlet fever 
from that of the common erythema which occurs in such diseases as pneu- 
monia, and in cases where certain drugs, such as belladonna, have affected 
the skin and the efflorescence comes out everywhere at once and has an 
irregular distribution. It also enables us to distinguish the disease from 
measles, in which the efflorescence begins on the sides of the neck and on the 
face and extends downward. On gently drawing the finger over the efflo- 
rescence of scarlet fever the resulting white mark remains longer than is the 
case with a common erythema. The efflorescence of scarlet fever continues 
to extend over the body for two or three days after its first appearance. 
During this period the tongue is much reddened and its papillae appear 
very prominent, constituting what has been called the ^^ strawberry tongue.'' 
There is at times in this stage great irritation of the skin. 

There may be slight delirium even in mild cases during the stage of 
efflorescence. This delirium may be very active and yet not be of serious 
import, provided the temperature remains moderate. 

The temperature rises when the efflorescence appears, and reaches its 
maximum at the end of the outbreak, in uncomplicated cases, but there is no 











CHAET 


14. 














Da.i/s o/^J?is€€Zse 




F 


1 


2 


3 


4 


5 


6 


7 


8 


9 


10 


II 


12 


c 


107° 
106° 
105° 
104° 
103° 
102° 
101° 
100° 
99° 

NORML 

97° 
96° 
95° 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


416° 

41.1° 

40.5° 

40.0° 

39.4° 

38.8° 

38.3° 

37.7° 

37.2° 
37 0° 

36 6° 

36.1° 
35.5° 
35,0° 
























































/ 




















/ 


/ 


V 


















1 


/ 






1 














:'■ 


/ 








U 


/ 














/ 










1/ 


^ 












/ 














\/ 


u 


i 






L. 


... 


--- 








— 


'- 


... 


\^ 


yC 


^ 



















































































Benign and regular form ot scarlet fever. 



decided rise just before or fall after the height of the efflorescence, as is 
the case in measles ; on the contrary, the temperature slowly diminishes until 
the ninth or tenth day from the beginning of the prodromal symptoms, 
when it becomes about normal, showing no decided crisis such as is seen in 
measles, but representing what is called lysis. 



544 PEDIATRICS. 

The pulse is quickened duriug the period when the temperature is 
elevated, and corresponds to it. It varies from 120 to 160. 

This chart (Chart 14, page 543) represents the temperature as it com- 
monly occurs in cases of scarlet fever of the benign and regular form. 

The vomiting usually ceases in the stage of efi&orescence, and often before 
the prodromal stage is ended. 

Desquamation. — The stage of desquamation begins at about the seventh 
day from the time when the efflorescence first appears, and in the parts of 
the skin first attacked. The desquamation, however, is not always propor- 
tionate to the intensity of the efflorescence. This desquamation is at first 
composed of small particles of cutis, but these soon become larger, and early 
in the third week from the beginning of the disease they fall from the body 
in large flakes. This form of desquamation is called lamellar. Here again 
we have an important means of distinguishing scarlet fever from measles, 
for in measles the desquamation is almost universally of a furfuraceous 
character through the whole course of the disease, Avhile the characteristic 
desquamation of scarlet fever is lamellar. This lamellar form of desquama- 
tion may at times, in certain individuals, and following the more intense 
inflammations of the skin, be represented by large and extensive pieces of 
skin. This is well shown in a specimen in the Warren Museum, where 
large strips of skin have come from the hand of a patient with scarlet fever 
so as almost to form a glove. 

Sometimes the desquamation lasts only ten days, but it may continue for 
two or three weeks. It is especially slow in disappearing from the hands 
and feet, and it may remain between the fingers and toes for a number of 
weeks. Sometimes after the desquamation has apparently ceased and the 
skin has been smooth and normal for several days it may begin again, and 
thus prolong the period of convalescence. 

Urine. — The utine is lessened in amount during the prodromal stage, 
returns to the normal amount in the stage of efflorescence, increases during 
the stage of desquamation, amounting at times to a polyuria, and returns 
again to the normal amount at the end of this stage. During the stage 
of efflorescence, especially if the temperature is considerably heightened, 
there may appear in the urine a small amount of albumin, but this dis- 
appears as the temperature subsides, is probably only the result of the fever, 
as in many other diseases accompanied by a high temperature, and is not to 
be confounded with the albuminuria of the nephritis which in some cases 
complicates the stage of desquamation. 

There is considerable reason to suppose that a mild form of nephritis 
accompanies almost every case of scarlet fever, although in many cases no 
clinical symptoms pointing towards the kidney appear and nothing abnormal 
is found on examination of the urine. This statement, however, rests to 
such a degree on the authority of the general practitioner, rather than on 
that of the expert in urinary analysis, that we shall probably in the future 
find the number of cases which show nothing abnormal in the urine greatly 



THE EXANTHEMATA. 545 

lessened when the number of expert examinations of the urine in mild cases 
of scarlet fever has increased. 

Prognosis. — The prognosis of the benign and regular form of scarlet 
fever is in almost every case favorable. It is comparatively rare for the symp- 
toms to become sufficiently serious to cause death unless some complication 
has arisen in the course of the disease. The individual who succumbs to 
the simple uncomplicated form of scarlet fever, even when the initial tem- 
perature is high and the symptoms are severe, as a rule must have been 
unusually vulnerable to the toxic effects of the scarlet fever contagium, or 
must have had a very low degree of vitality at the beginning of the 
disease. 

Diagnosis. — The diagnosis of the benign and typical form of scarlet 
fever is not difficult. Its incubation is decidedly short in comparison with 
that of any of the other exanthemata. Its prodromal stage is short in 
comparison with that of variola and measles, and longer than the exceed- 
ingly brief prodromal stage of varicella. The characteristic prodromal 
symptoms of sore throat and a general and intense hypersemia of the mucous 
membrane, accompanied by vomiting and severe constitutional symptoms, 
make it easy to differentiate it from measles, varicella, and variola, none of 
which, as a rule, show these symptoms. 

The punctate erythematous lesions which appear in the stage of efflores- 
cence of scarlet fever are rarely met with in any of the other diseases of 
this group. This efflorescence, beginning on the neck and chest and ex- 
tending upward and downward, is distinguished by its peculiar distribution 
from that of the other members of the group. 

The lamellar desquamation is very characteristic, and is seldom seen in 
any of the other exanthemata. 

The complications arising in the ear, and the occurrence of nephritis as a 
common sequela in scarlet fever, do not to the same degree find their counter- 
parts in varicella and measles. 

Treatment. — As I have often told you in speaking of other diseases, 
so in scarlet fever, having an accurate knowledge of the chief pathological 
lesions which occur during the course of the disease, you can easily deduce 
the appropriate treatment. By treatment, you must understand, I do not 
mean simply the use of drugs. On the contrary, I would impress upon 
you that in my opinion drugs are employed to entirely too great an extent 
in a large proportion of the uncomplicated cases of the benign type of 
scarlet fever. I feel that I can speak with some authority on this point, as 
it has been my rule for many years to compare the results of cases treated 
by my colleagues with drugs with my own cases treated without drugs, and 
certainly nothing that I have observed in this comparison would indicate 
that my patients had suffered from want of treatment. We should have 
some definite reason for what we do, and should not be influenced by vague 
ideas of what drugs are supposed to be beneficial in certain diseases. 

The treatment of a case of scarlet fever is that of a self-limitcnl disease. 

36 



546 PEDIATRICS. 

With our present knowledge of it, the disease cannot be cut short. We 
should, therefore, endeavor to keep it within its own limits by avoiding 
complications. To do this we must remember which tissues are affected as. 
part of the disease and which are likely to be affected by complications. 

In the first class, as I have already explained, we must consider the 
throat and the skin ; in the second class the ear and the kidney. Remember^ 
gentlemen, that I am now speaking of the mild cases of scarlet fever^ 
and that the severe and complicated cases must receive their appropriate 
treatment as they arise. 

The treatment here in my scarlet fever ward is rendered much easier 
than is the case in private houses by the fact that I am absolutely free 
from family prejudices as to how scarlet fever should be treated, and also 
because the patient can at once be put in a room from which all unnecessary 
paraphernalia have been removed. As, however, your cases in practice will 
be in their homes, it will be better for me to describe the general manage- 
ment and treatment of .scarlet fever outside of hospitals. 

At the onset of the disease the child, as a rule, is so profoundly affected 
by the scarlet fever contagium that it wishes to be put to bed at once. 
The symptoms which from their intensity require treatment in the pro- 
dromal stage of the disease are the vomiting, the sore throat, and the higk 
temperature. 

The vomiting, as a rule, is of such short duration, and is so symptomatic 
of nervous gastric disturbance caused by the toxic effect of the poison, that 
it should be looked upon as eliminative, and usually does not require the use 
of anything but pieces of cracked ice to be held in the mouth. 

The treatment of the throat in scarlet fever is to be especially directed 
not only to allaying the temporary discomfort of the pharyngitis, but also 
to preventing the inflammatory process from extending through the Eusta- 
chian tubes to the membranse tympani and producing an otitis which may 
result in a meningitis. This latter complication is rendered possible by the 
close vascular connection which exists in infancy and in childhood between 
the meningeal blood-vessels and the vessels of the tympanum through the 
open petro-squamosal suture. 

Another reason for systematically treating the throat in all cases of 
scarlet fever is derived from the belief that the various secondary infec- 
tions which take place in the disease are probably caused by the entrance of 
pathogenic organisms to the various tissues through the inflamed and vul- 
nerable mucous membrane of the pharynx. This invasion is commonly of 
the cervical glands, the ear, the lung, the heart, and the kidney. If this 
belief is correct, antiseptic treatment directed to the throat is indicated as 
possibly preventive to the complications which may arise in the disease. 

For the purpose not only of allaying the irritation of the throat, but 
also of preventing the spread of the morbid process to the ear, if possible, 
the throat and the nose may be sprayed several times during the day. 
Solutions of borate of sodium in water combined with a small amount of 



THE EXANTHEMATA. 547 

glycerin are useful for tliis purpose. A four per cent, solution of boric acid 
in water can also be used to advantage. The local treatment, however, 
should always be of the mildest form, since anv additional ii'ritation of the 
mucous membrane will render it more vuhierable to the streptococcus inva- 
sion. If the child knows how to gargle, the discomfort which arises usually 
from the sore throat during the first day or two of the disease may often 
be allayed by simply gargling with cool water. This procedure answers a 
double piu-pose : it not only reduces somewhat the hyperEcmic condition of 
the mucous membrane of the upper part of the throat and cleanses the 
anterior fauces, but also tends to prevent the extension of the pathogenic 
organisms which woidd necessarily be favored by a contmuous recumbent 
position of the child. If the child is unable to gargle, some pieces of ice 
may be given to it to hold in its mouth, and it should occasionally be allowed 
to sit up, as when its nourishment is being given. 

However desirable this treatment of the throat and nose may be in 
scarlet fever, we are but too often bafSed in oiu* attempts to treat them 
locally, on accoimt of the persistent resistance of the child. 

Chlorate of potash, which is so frequently used for the treatment of 
the throat in scarlet fever, is, in my opinion, a drug which in this disease it 
will be wiser not to allow the child to swallow, on accoimt of its possible 
deleterious action on the kidney, which fr'om the beginning of the disease 
to its end is in so sensitive a condition as to be readily affected by any 
irritant. Doubtless in a large number of cases we should not be likely 
to cause renal irritation by the small doses of chlorate of potash which 
are usually given. Children, hoAvever, differ very much in their individual 
susceptibility^ to di'ugs, and we can never tell beforehand whether or not 
a child is liable to be injm-ed by them. ^Ve know that the vegetable 
salts of potash are decomposed in the system and eliminated as alkaline 
carbonates, thus causing no iiTitation in the kidney. Nitrate and chlo- 
rate of potash, on the other hand, which do not part with theii' oxygen in 
the system, are excreted undecomposed by the kidney, and thus act as irri- 
tants. Knowing that the tendency during the whole com^e of the disease 
is towards a renal hyper^emia, we should allow the child to have plenty of 
water to drink. 

Unless the child shows decided signs of suffering from a heightened 
temperature, I do not use antipyretics in the form of drugs by the mouth, 
as the cases are rare where a temperature of 38.8° to 39.4° C. (102° to 
103° F.) for a few days will do harm. This is a safe rule to follow in a 
disease like scarlet fever, where, if the child happens to be easily atlect(\l by 
fever, the unfavorable symptoms will appear at once and can be attended to. 
My opinion is that mere heightening of the temperature without correspond- 
ingly severe symptoms causes much needless anxiety. In typical mild cases 
of the disease I should, knowing that a lessening of the amount of the urine 
in the prodromal stage as a result of the high temperature is a part of the 
regular com-se of the disease, discoimtenance the administration of diuretics 



548 PEDIATRICS. 

beyond a plentiful supply of pure drinking-water. The temperature, al- 
though it may cause severe initial symptoms, such as convulsions, as a rule, 
does not have to be directly treated during the prodromal stage. If, how- 
ever, convulsions occur and continue and the temperature is unusually high, 
such as 40.5° or 41.1° C. (105° or 106° F.), and if it remains at this height 
with serious general symptoms, such as delirium, you should endeavor to 
reduce it by sponging the body with water, the temperature of which should 
be varied according to the special case. To begin with, the temperature 
of the water should be about 32.2° C. (90° F.). 

I have mentioned before that scarlet fever is rare during the first year 
of life. There are certain observations which seem to show that nephritis 
is a rare accompaniment of scarlet fever during the first year. We know 
that milk is the food which is least irritating to the kidney. It would, 
therefore, seem but rational to make milk the diet in a disease which, like 
scarlet fever, points out to us by its pathology that we should as far as 
possible avoid irritating the kidney. It may be merely a coincidence, but 
it seems of some significance that the first year of life should also be the 
one which is least likely to present cases of scarlatinal nephritis. For this 
reason I am in the habit of putting my patients with scarlet fever absolutely 
on a diet of milk from the beginning to the end of the disease, or at least 
for four weeks. Perhaps in this way in a certain number of cases nephritis 
may be warded off, and if it develops, the patient is already on a diet which 
is best suited to the disease. 

When the nausea and vomiting are present, the child, as a rule, feels too 
sick to take any nourishment whatever. When the violence of the toxic 
invasion has somewhat abated, and the diagnosis of scarlet fever has been 
made, orders should at once be given that the child is to have no food but 
milk. The treatment of scarlet fever with a diet purely of milk has in my 
practice proved so eminently satisfactory that it has become my routine 
treatment of the disease. During the initial stage of the disease, and until 
the stomach has recovered its equilibrium, lime water should be added to the 
milk in the proportion of one part to ten. Later the alkalinity of the milk 
can be lessened, and after the early days of the efflorescence the milk may 
in most cases be given undiluted. The administration of milk alone should 
be continued through the stages of efflorescence and desquamation, and until 
you are justified in supposing that a nephritis will not develop in the special 
case. This in general may be estimated at from four to five weeks from the 
time of the height of the efflorescence and temperature. 

During the stage of efflorescence there are seldom any symptoms which 
require special treatment, in the regular form of the disease, except a con- 
siderable irritation of the skin which at times arises. This can be allayed 
by the application either of some simple ointment or of a powder of oxide 
of zinc and starch (Prescription 56). The use of the ointment is to be recom- 
mended not only because it keeps the skin soft and in good condition, but 
also because this application reduces the temperature somewhat. Sponging 



THE EXANTHEMATA. 549 

the entire body with water at a temperature of 32.2° C. (90° F.), once or 
twice daily according to the comfort of the patient, is to be recommended. 

During the stage of desquamation the application of a simple ointment 
to the whole body is desii'able both for the purpose of softening the dis- 
integrated epitheliimi and lessening the duration of this stage, and also 
to prevent the spread of the contagimn by means of the loosened scales. 

The child should be kept m bed until the desquamation has almost 
entirely ceased. This will cover a period of from four to five weeks. By 
the end of the fourth week, if the desquamation has completely disappeared, 
the diet can gradually be increased by the addition of soup and bread. It is 
well to keep the child in the house for five or six weeks, and still longer 
if the weather is cold or damp. 

The urine should be frequently tested for albumin dming the first three 
weeks, and afterwards when the child is first allowed to get up, after each 
change in diet, and after going out. If any albumin is detected, the child 
should be immediately put back to bed and on a diet of milk until 
the albimiin has disappeared. Remember that the mild cases are the very 
ones in which a nephritis is liable to occur, and therefore we should watch 
them vigilantly until they are out of danger, which is usually in the fifth or 
sixth week. 

Isolation axd Disintectiox. — The disease being eminently infectious, 
the patient with its nurse should be isolated to as great a degree as circum- 
stances will permit. An upper room should be chosen preferably. It has 
been observed in crowded parts of large cities that scarlet fever in tenement- 
houses is not so likely to spread when the first cases are in the top rooms 
of the tenements. In a number of instances in my practice I have had 
one child of a numerous family strictly isolated in the upper story of the 
house, and the other children have remained in the house without contract- 
ing the disease. 

The intensity of the lesions of the skin and the involvement of large 
sm-faces indicate that the air of the room should be kept at an equable tem- 
perature, in order that the function of the disabled skin should be taxed 
as little as possible and that the internal organs should not have too great 
compensatory work forced upon them. The temperature shoidd be kept 
at about 20° C. {QS"" F.). 

A disease which renders necessary confinement to the room for weeks 
demands a room with good ventilation and plentiful sunlight. Therefore a 
room on the sunny side of the house, having an open fireplace, should he 
chosen. 

The room should be free from all cotton or woollen materials except 
such as can be destroyed by fire at the end of the disease. The blankets, 
sheets, towels, and clothes can, of course, be disinfected, but it will save 
much ultimate trouble to remove tlie carpet and the curtains and repUice 
them with pieces of old carpet and sheets. The pictures, and in fact every- 
thing worth preserving, had better be removed. The room can be made 



550 PEDIATRICS. 

cheerful enough by means of cheap colored prints and destructible toys to 
amuse the child. 

During the whole course of the disease the greatest care must be taken 
to disinfect the linen of both the patient and the nurse. This should be 
done by soaking it for twenty-four hours in a five per cent, solution of 
carbolic acid, then boiling it for half an hour in water, and finally washing 
it with soft soap solution, 20 grammes (f ounce) to 10 litres (10 J quarts) of 
water. 

The dejections are to be received in a vessel one-quarter full of a five per 
cent, solution of carbolic acid. 

After the child is entirely well it is to be thoroughly washed first in 
a solution of corrosive sublimate 1-2000, and then immediately with water, 
so as to avoid irritation of the skin. The child is then to be taken to 
another room to be wiped and put into fresh clothes, which, of course, 
have not been in the scarlet fever room. The mattress is to be tied up in 
canvas wet with a corrosive sublimate solution 1-500, and sent out of the 
house to be disinfected, if possible by steam. I usually advise the family 
never to have it brought back again. In place of the mattress it is far 
better to use old blankets, which, if in sufficient number, are comfortable, 
and at the end of the sickness can be thoroughly boiled and thus disin- 
fected. The useless articles which have been in the room during the sick- 
ness should be burned in the open fireplace. 

The room must next be disinfected. This is a very difficult matter to 
do absolutely, but there are several methods which are far better than the 
usually recommended disinfection by sulphur which has been so generally 
used for this purpose during the past century. I mention sulphur as a dis- 
infectant merely to tell you that it was proved by Koch as long ago as 1881 
to be entirely unreliable. 

If there is paper on the walls, it should be scraped off and immediately 
burned. The floor should then be washed with a solution of corrosive sub- 
limate 1-500, followed by soap water. The ceilings, the walls, all the wood- 
work, and the furniture are to be thoroughly rubbed with bread and then 
wiped with the corrosive sublimate solution 1-500. Esmarch has shown 
that bread is the best means for removing infectious material from surfaces 
of this kind. The micro-organisms adhere with great tenacity to the bread, 
which, with any crumbs that break off and fall to the floor, must be care- 
fully collected and destroyed by fire. The room should then be aired for 
several days. I always advise the family, if there are other children in 
the house, to have the whole room, including the ceiling and the floor, 
painted. 

You must also bear in mind that you, by means of your hair, beard, 
and clothes, are the possible means of transmitting the contagium from one 
patient to another, and that it is your manifest duty to the public to change 
your clothing and disinfect yourselves on leaving a scarlet fever patient. 

This case (Case 237), the notes of which I find in my records, will, I 



PLATE YII 





Ccpyrijfit 1894 by J. B. Lippincoti Company 



THE EXANTHEMATA. 551 

think, serve to show you the characteristics of the benign type of scarlet 
fever without variation from the regular type and without complications : 

A boy four and one-half years old was noticed by me on November 6, wben I was 
vaccinating bis sister, an infant, to be quite sick. Besides the infant the boy's two brothers, 
•one two and a half years old and the other six, were in the room with him. The mother 
supposed that the boy had an attack of indigestion. He had been vomiting quite frequently 
and had no appetite. His pulse was 120. His temperature was 38.3° C. (101° P.). He 
had no headache and no sore throat, but he had the appearance somewhat characteristic of 
scarlet fever well marked on the hard and the soft palate. He was placed in an upper room 
of the house and completely isolated with a trained nurse. The vomiting continued until 
•evening, when it stopped and did not return. 

On November 7 he was reported to have had a restless night. His throat was found to 
"be very much reddened and to feel a little sore. His pulse was 135. His temperature was 
•38.3° C. (101° F.). He had had a natural movement of the bowels. His appetite was 
poor. 

All unnecessary articles were immediately removed from the room, and he was confined 
to his bed. He was placed on a diet of milk and given as much water as he wished to 
drink. The efflorescence of scarlet fever very soon appeared on his chest. 

On November 8 the efflorescence had spread all over his body. He was reported to 
have slept well and to have vomited his milk but once. His pulse was 125, and his tem- 
perature was 37.7° C. (100° F.). He was sponged twice daily with water at a temperature 
of 32.2° C. (90° F.), and as the skin was somewhat irritable the itching was allayed with 
inunctions of vaseline. The temperature of the room was kept at 20° C. (68° F.). 

On November 9 the efflorescence had spread to the limbs, and was also present to a 
slight degree on the face. At 6 a.m. the pulse was 120, the temperature 36.6° C. (98° F.). 
At 6 P.M. the temperature was 37.2° C. (99° F.), and the pulse was 120. He had a little 
more appetite, his skin was less reddened, and his throat was not so sore. 

On November 11 the efflorescence began to fade, first on the chest. On November 13 
the temperature became normal, and desquamation began, first on the chest. On November 
25 the desquamation had almost ceased, and the boy was allowed to get up and play about 
the room for an hour. On December 1, the desquamation having almost ceased for several 
days, he began to desquamate freely again. On December 8 the desquamation ceased. He 
was disinfected and then sent down-stairs among the rest of the children. He went out of 
doors December 25. 

No albumin was detected in his urine during the whole course of the disease. He 
resumed his usual diet on December 10. 

None of the other children contracted the disease, although they remained in the house 
while their brother was sick. 

I shall now show you in this bed a typical case of the benign form of 
scarlet fever with the distinctive efflorescence of the disease on the chest, 
neck, and face. 

The boy (Case 238, Plate YII., Scarlet Fever) is ten years old. He is said to have 
been exposed to scarlet fever eight days ago. He was taken sick, with sore throat, vomit- 
ing, a quickened pulse, and heightened temperature, four days ago. Three days later this 
efflorescence appeared, first on his neck and chest, and later it spread downward over the 
trunk and extremities and upward to the face. The efflorescence is, as you see, in the form 
of a punctate erythema. You will notice that the degree of redness is much changed 
according as the skin is protected by the warmth of the bedclothes or is exposed for a 
greater or less time to the temperature of the room. 

There is, therefore, no definite color or degree of red color which is characteristic of 
scarlet fever, as it is liable to vary from many causes. The vomiting ceased three days ago. 
The boy has been at times slightly delirious for the past two days, but to-day the toinpeni- 



552 PEDIATKICS. 

ture, which for the previous three days has risen to from 40° to 40.5° C. (104° to 105° F.), 
is beginning to fall, corresponding to the maximum of the efflorescence having been passed. 
His mind is now perfectly clear. 

There has been until to-day a trace of albumin in his urine, but no casts have been 
detected, and it has been only slightly lessened in quantity. 

He has no complications. Although he looks quite sick, he represents merely a pro- 
nounced and typical example of the benign and regular form of scarlet fever. On entering 
the hospital he was placed at once on a diet of milk. He takes and digests the milk well, 
and, unless some complication arises, he shall have no medicine given him, nor shall he have 
any food but milk for at least four weeks. 

Vaeiations in the Benign Form. — In the benign form of scarlet 
fever we may have great variations from the typical manifestations of the 
disease which I have just described to you. 

A heightened temperature in the evening sometimes continues for over a 
week after the efflorescence has faded, without the existence of any ascertain- 
able cause : this occurrence should always be looked upon with suspicion. 
After a rapid increase of temperature at the beginning of the disease there 
sometimes ensues a condition of complete apyrexia, while all the other 
symptoms continue to develop in the usual manner. When the temperature 
remains heightened at the end of the period of efflorescence and continues 
into the period of desquamation, especially when there is no local pain any- 
where, we should suspect that a nephritis may be developing. When the 
temperature after having become normal rises again, we should suspect such 
complications as otitis and suppuration of the subcutaneous tissues of the 
neck, or that the heart is involved. 

Relapses may take place in scarlet fever. In some of these cases after 
the efflorescence has disappeared it may return in the second or third week, 
during the stage of desquamation, and even after the desquamation has 
ended. The symptoms of these cases are sometimes more severe than those 
in the first attack, but in most of the reported cases of relapse in scarlet 
fever the first attack has been a mild one. Such cases occur usually in 
older children rather than in younger, and must be sharply distinguished 
from the cases where a fresh infection has taken place and which are charac- 
terized as a second attack of the disease. Thomas reports a case of scarlet 
fever complicated by varicella, in which on the twenty-fifth day of the 
scarlet fever a relapse occurred, and on the twenty-sixth day a second 
attack of varicella developed. 

Certain cases of scarlet fever have been reported in which in the latter 
part of the disease, and after the temperature had become normal, the tem- 
perature rose to 40°-41.1° C. (104°-106° F.), where no cause could be dis- 
covered for the hyperpyrexia, and where the patients recovered after being 
promptly treated with cold baths to reduce the temperature. 

Scarlet fever may begin with such great cerebral excitement as to. lead us 
to suspect meningitis, and it may not be possible to determine the diagnosis 
until the efflorescence has appeared, which may not be until even the eighth 
or ninth day. 



THE EXANTHEMATA. 553 

The efflorescence may last only twenty-four hours, or it may last fourteen 
days. We must remember that we are not to depend upon the efflorescence 
in making our diagnosis in scarlet fever, as it may be so evanescent as to be 
scarcely recognizable. 

Convulsions occurring at the onset of the disease are not, as a rule, 
indicative of a fatal issue, but when they occur later they are usually of 
serious import. 

The occurrence of scarlet fever in surgical cases is of no special sig- 
nificance beyond the apparently greater susceptibility of patients with open 
wounds to contract the disease. We should bear in mind the suggestion of 
Osier, that in the majority of these surgical cases thus far recorded the efflo- 
rescence has probably been the red rash of septicaemia, and that the reported 
cases have become rare since the gradual disappearance of septicaemia as a 
complication of surgical operations. Atkinson also suggests that in many 
cases these rashes may have been due to the quinine which was given to the 
patient. 

A variation may arise from the ordinary scarlatinal inflammation of the 
mucous membrane of the throat becoming more severe than usual and re- 
sulting in exudation. The larynx in some cases may also present unusual 
symptoms, such as aphonia, and serious symptoms caused by a concurrent 
cedematous condition of the glottis may arise and even produce a fatal issue. 

I have in this next bed a case which represents certain variations from 
the typical symptoms which occur in the throat and nose, and which are 
very mild in their character : 

This boy (Case 239), three years old, was attacked four days ago. The invasion of the 
disease was characterized by drowsiness, loss of appetite, malaise, slight nausea, a quick- 
ened pulse, a temperature of 39.1° C. (102.5° F.), and intense sore throat. 

On the second day of the disease the temperature continued to rise, and in the latter 
part of the day a punctiform erythema appeared on the neck, and later on the face and hands. 
During the next night he was very restless, sleeping only five or ten minutes at a time, and 
complaining of his throat, of headache, and of being very thirsty. His breathing was rather 
rapid. On the morning of the third day the record showed that in the past twenty-four 
hours he had taken only 120 c.c. (4 ounces) of milk ; he had had no movement of the bowels 
and had passed 300 c.c. (10 ounces) of urine. His pulse was 134, his temperature 39.4° C. 
(103° P.), and his respirations 34, In the evening the pulse was 134, temperature 39.6° 
C. (103.5° F.), and respirations 30. His throat continued to be painful. The whole throat 
was reddened, and the tonsils were enlarged. There was a thick muco-purulent discharge 
from the nose. The glands of the neck on each side were enlarged. There was consider- 
able irritation of the skin during the day, which was relieved by the occasional use of a 
lotion containing carbolic acid 4 c.c. (1 drachm) to water 473 c.c. (1 pint). 

This morning he was reported to have had a very restless night, to have taken 420 c.c. 
(14 ounces) of milk in the twenty-four hours, to have had one movement of the bowels, 
and to have passed 600 c.c. (20 ounces) of urine in the twenty-four hours ; the temperature 
was 38.6° C. (101.5° F.), pulse 128, and respirations 28. The child is very irritable and rest- 
less. You see that there is a constant copious muco-purulent discharge from the nose, and 
that he coughs quite frequently. The glands on each side of the neck are still considerably 
swollen. The scarlatinal efilorescence has invaded the entire body, has extended over the 
limbs, and is accompanied by considerable irritation. On examining the throat you will see 
that its entire mucous membrane is verv much reddened and that the tonsils are swollen. 



554 PEDIATRICS. 

On both tonsils, especially on tlie left, are some small yellowish-white spots apparently 
connected with the crypts. In one place these spots have coalesced. There is also consid- 
erable exudation, though apparently not of a membranous character, in the pharynx. I 
shall have a bacteriological examination made from the exudation in various parts of the 
throat. Material for this examination can be procured by means of a sterilized platinum 
wire, which you see can be easily used, as the child does not object to opening his mouth and 
allowing me to use the wire. 

(Subsequent history of the case.) On the evening of the fourth day the temperature 
rose to 39.6° C. (103.5° F.), the pulse was 124, and the respirations were 28. 

On the fifth day the report was that during the previous twenty-four hours the child 
had taken 540 c.c. (18 ounces) of milk and had passed 660 c.c. (22 ounces) of urine. He 
had slept better, but, owing to the extreme restlessness, he had been given 0.6 gramme (10 
grains) of bromide of soda during the night. The eflorescence was beginning to fade. 
The throat was not so sore, and there was no appearance of any newly-developed morbid 
conditions in it. 

On the sixth day of the disease the temperature in the morning was 37.7° C. (100° F.) 
and in the evening 39.6° C. (101.3° F.) ; 300 c.c. (10 ounces) of milk had been taken in 
the previous twenty-four hours and 915 c.c. (30J ounces) of urine had been passed. There 
was decided improvement in the throat and nose. 

The bacteriological report stated that in the culture made from the exudation which 
had been taken from the throat the Klebs-Loefla.er bacillus could not be found. 

On the seventh day of the disease the temperature in the morning was 37.4° C. (99.4° 
F.) and in the evening 38.5° C. (101.5° F.). Although the appearance of the throat had 
improved, the patient was very fretful, and the voice was quite hoarse. 

On the eighth day the child had become much more hoarse, and was unable to speak 
except in a whisper. The discharge from the nose had ceased. The temperature in the 
morning was 37.4° C. (99.5° F.) and in the evening 38.2° C. (100.8° F.). 

On the following day, the ninth from the invasion of the disease, the child was much 
brighter; his appetite returned, so that he took 1200 c.c. (40 ounces) of milk in the twenty- 
four hours, and he passed 840 c.c. (28 ounces) of urine. The swelling of the glands in the 
neck had almost disappeared, and the throat showed no evidence of irritation. 

From this time the temperature continued to vary from 37.5° C. (99.5° F.) in the morn- 
ing to 37.7° C. (100° F.) in the evening until the thirteenth day, when it became normal. 
Desquamation began on the eighth day and continued until the twentieth day. No other 
symptoms arose, and there was no disturbance in connection with the kidney. He recovered 
his voice on the nineteenth day. 

In the benign form of scarlet fever certain cases are at times met with 
in which the high temperature, or the especial vulnerability of the child to 
the scarlet fever contagium, causes the symptoms to vary considerably from 
the typical form and to be unusually grave. As an instance of this class of 
cases I will report to you one which was seen by me in consultation with 
Dr. Robert P. Loring, of Newton Centre. 

The child (Case 240) was a girl, six years old. The point of variation from the typical 
cases of scarlet fever was in this case an unusually high temperature. The invasion of the 
disease was characterized by restlessness and sore throat, which were soon followed by vomit- 
ing and delirium. The temperature on the first day rose to 41.1° C. (106° F.). The highest 
temperature was on the second and third days, when it reached 41.6° C. (107° F.). During 
the first three days the pulse could not be counted. The high temperature continued until 
the sixth day from the beginning of the prodromal symptoms. There was great gastro- 
enteric disturbance, and during the first forty-eight hours there was almost continuous 
vomiting. This was succeeded on the third day by frequent profuse, and often involuntary, 
serous discharges from the bowels. These discharges continued until the fifth day. On the 
fourth day a slight erythematous efflorescence appeared on the neck and chest, and on the 



THE EXANTHEMATA. 



555 



fifth day it extended all over the body and was of an intense character. On the sixth day 
a complication of pain in the wrists began, but it disappeared in twenty-four hours under 
the administration of salicylic acid. At this time also there was considerable swelling on 
the left side of the neck, which gradually disappeared in four or five days. When the 
fever was at its height there was considerable cyanosis, with quickened respiration. The 
pulse at this time was weak and difficult to count. From time to time during the attack 
antifebrin was given for the restlessness, and bromide of soda was occasionally used. Tinc- 
ture of digitalis was given when the pulse was quick and weak and cyanosis was present, 
but the treatment which was most depended upon was by bathing. 

The method of bathing for the purpose of reducing the temperature was that of 
placing the child in a tub of water. Whenever the temperature reached 40.5° C. (105° P.) 
the child was placed on a pillow in the bath, and was kept there until the temperature was 
reduced three or four degrees. The time required to accomplish this was usually from 
one to one and a half hours. While the child was in the bath stimulants and milk were 
given to it. The temperature of the water was about that of the child, and was gradu- 
ally reduced to about 32.4° C. (90.5° F.). During the first four days the child was either 
delirious or in a comatose condition, and when in the bath would pass its urine and faecal 
discharges involuntarily. 

The high temperature continued until the sixth day from the beginning of the prodromal 
symptoms, when it fell decidedly, from which time the baths were omitted, and the tem- 
perature continued to fall by lysis until it reached the normal degree on the sixteenth 
day from the invasion of the disease. After this the child had no unusual symptoms, 
and made a rapid recovery. There were no complications. The desquamation took the 
usual course. 

Here is the chart (Chart 15) of this case. The broken lines show the degree to which 
the temperature was reduced by the baths. 

CHAKT 15. 





J)czys of DtsecLse 




F 


1 


2 


3 


4 


5 


6~ 


7 


8 


9 


10 


II 


12 


13 


14 


15 


16 


17 


18 


19 


20 


21 


c 


1.07° 
106° 
105° 
104° 
103° 
102° 
101° 
100° 
99° 

NORMb 
TEMP 

98° 
97° 
96° 
95° 


W K 


M E 


ME 


M E 


M E 


M E 


51 E 


M E 


M E 


M E 


MtE 


M E 


M.E 


Bl £ 


M E 


M E 


M E 


M E 


Tf-E 


M E 


Jl B 


41,6° 

41.1° 

40.5° 

40,0° 

39.4° 

38.8° 

38.3° 

37.7° 

37.2° 
37.0° 
36 6° 

36.1° 

35.5° 

35.0° 




/ 


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y 


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Toxic symptoms and high temperature in scarlet fever treated by baths. 



Complications and their Treatment. — Most of the complications 
"which arise in scarlet fever are due probably to the action of streptococci, 
either isolated or associated with other micro-orp^anisms. These micro- 
organisms produce serious symptoms, which are often followed by death, 



556 PEDIATKICS. 

either directly by giving rise to septicsemic processes or indirectly by 
nephritis. 

It is supposed that the infection which complicates scarlet fever enters 
the system commonly through the pharynx either by direct absorption or by 
inhalation of these organisms. 

Throat. — In addition to the milder forms of inflammation in the throat 
which occur in the course of scarlet fever, this simple inflammation may 
be complicated by more severe lesions. In these cases there may be an 
exudation aflecting the mucous membrane of the entire buccal cavity and 
throat, evidently produced by streptococci. This complication adds greatly 
to the severity of the scarlet fever, and is a common source of invasion of 
the ear and of infection of the cervical glands. In addition to lesions of 
this class you will at times meet with a membranous condition of the 
mucous membrane of the throat, the pathological lesions of which cannot 
be differentiated from those of diphtheria. This membranous condition 
is caused by the action of streptococci, and the diagnosis between these 
membranes and those which are produced by the Klebs-Loefiler bacillus 
cannot be made except by means of bacteriological examination. These 
more severe inflammatory conditions of the throat are not common in my 
experience outside of hospitals, but have been observed a number of times 
in our scarlet fever and diphtheria wards at the City Hospital. In these 
cases of streptococcus invasion the entire throat may be very much swollen, 
the tonsils enlarged, and the naso-pharynx affected to such a degree as almost 
to occlude the nares. It is necessary to make a bacteriological examination 
of these lesions which have been called pseudo-membranes, if we wish to deter- 
mine in the early days of the disease whether or not we are dealing with a 
case of diphtheria. After the first three or four days in most cases there is 
usually so marked a clinical difference between the progress of the disease 
where the Klebs-Loeffler bacillus is present and that where the exudation is 
simply secondary to a streptococcus invasion, that we are not long in doubt 
as to our diagnosis, even without the decisive proof by culture. As a rule, 
where the Klebs-Loeffler bacillus is present the continued increase in the 
severity of the symptoms and the resulting exhaustion of the child show us 
that we are dealing with this micro-organism. We must not, however, be 
misled by this general rule of differential diagnosis, for there are many 
cases in which it is impossible to differentiate between a streptococcus inva- 
sion and an invasion of the Klebs-Loeffler bacillus either by the appearance 
of the throat or by the clinical symptoms. On the one hand, the strepto- 
coccus invasion may be quite as severe in its symptoms as that of the 
Klebs-Loefller bacillus, while, on the other hand, true diphtheria may occur 
where the symptoms are as mild as any that are produced by the other 
micro-organisms. 

The treatment of the throat in these severe secondary conditions is the 
same as I have already spoken of in the treatment of the benign forms, except 
that, if possible, it should be carried out more rigorously. As the disease 



THE EXANTHEMATA. 557 

runs a comparatively short course, there is not such a need for stimulants 
as is indicated where diphtheria is present. In young children it is often 
impossible to treat the throat locally, and I have usually found that my 
chief reliance in tiding over the severe stage of the disease is the admin- 
istration of sufficient food, and of stimulants when they are indicated by the 
general condition of the child. It is to be remembered, of course, that the 
throat in scarlet fever may be attacked by the Klebs-Loeffler bacillus and 
the disease brought to a fatal issue by a complicating diphtheria. When 
diphtheria is present, the treatment should be the same as for a primary case 
of diphtheria ; and this I shall refer to in a later lecture (Lecture XLII., 
page 828). 

In the more severe forms of inflammation in the throat the inflammatory 
process may go on to abscess, as in the pharynx, but the most common place 
is in the tonsil or in its neighborhood. These abscesses must be carefully 
watched for, and when detected opened with antiseptic precautions as soon as 
possible. We shall by this treatment often shorten the course of the disease, 
and thus save loss of strength and vitality on the part of the patient. 

As an example of one of the more severe lesions occurring as a com- 
plication in the throat in scarlet fever, I shall report to you a case which 
occurred in my practice. 

A boy (Case 241), two and a half years old, was seized on December 4 with diarrhoea, 
vomiting, and sore throat. On December 5 the tonsils were found to be enlarged and the 
whole throat much reddened. The efflorescence of scarlet fever appeared on the chest, and 
the child seemed dull and sick. The temperature was 40° C. (104° F.) and the pulse 150. 

On December 6 both sides of the neck were much swollen, and the tonsils were much 
enlarged. 

On December 7 there was considerable muco-purulent discharge from the nose, and the 
temperature was 39.7° C. (103.5° F ). The child was not so dull, and the efflorescence was 
■well marked over the whole body. 

On December 8 the diarrhoea continued, and the temperature and pulse remained about 
the same. The child took milk regularly, but refused to have any applications made to its 
throat or nose. 

On December 10 there was no especial change in the general symptoms, except that 
the diarrhoea was less and the throat and nose were rather sore. There was a peculiar 
grayish-white exudation around the mouth and throat which could be easily removed. The 
neck on both sides was swollen and hard. The pulse was rather weak, 140, and stimulants 
were given every two hours. 

On December 11 there were less hardness and swelling of the neck, and less discharge 
from the nose, the pulse was 150, the temperature was 39.4° C. (103° F.), and the efflo- 
rescence was fading. 

On December 12 there was much exudation from the mouth, but the child took more 
milk, and desquamation had begun. 

On December 13 the temperature was 38.8° C. (102° F.) and the pulse 150. The child 
cried a great deal, was very restless, and complained of pain in the joints, but the neck was 
less swollen. 

On December 14 the child vomited twice during the night. On December 15 the 
pulse was 135 and the temperature 38.3° C. (101° F.). On December 18 the temperature 
was 37.7° C. (100° F.), and there was a profuse flow of saliva: the breathing sounded as 
though the throat and posterior nares were considerably occluded. 

On December 20 the pulse, which had been decidedly weak, became stronger ; its rate 



558 PEDIATRICS. 

was about 150, and the temperature was 37.2° C. (99° "F.). The child seemed much 
brighter, and the throat was less troublesome. The pains in the legs, however, were quite 
severe. 

On December 21 the pulse was 148 and the temperature 36.6° C. (98° F.). There was 
considerable discharge from the nose, and there was an efflorescence of herpes on the lips 
and face. 

On December 23 both tonsils were found to be much enlarged and of a deep red color. 
The temperature from this time remained normal, and the child rapidly improved until 
December 28, when it complained of pain in the left ear : some hours later, perforation of 
the membrana tympani took place and there was a slight muco-purulent discharge. 

On December 29 both ears were gently irrigated with lukewarm water. Up to this 
time the urine had shown no abnormal condition, but on this day it was found to contain a 
faint traceof albumin, and the specific gravity was 1013.5. The sediment was small, and 
consisted of small round renal epithelium, mucous casts, and an occasional hyaline cast, 
representing a condition of hypersemia. From this time the child rapidly recovered, the 
temperature remained normal, the swelling and hardness of the neck entirely disappeared, 
the albumin and casts disappeared from the urine, and the ears recovered without result- 
ing deafness, but for over a year there was evidence of decided thickening of the tissues of 
the naso-pharynx. There was no subsequent paralysis. 

In this case the child resisted all attempts at treatment so strenuously that little 
was done beyond the administration of milk and brandy. A bacteriological examination 
of the exudate in the throat was not obtained, so that the Klebs-Loeffler bacillus could 
not be definitely excluded as a cause, but the subsequent course of the disease showed that 
in all probability diphtheria had not been present. It therefore represents very well the 
typical course, uninfluenced by drugs and special treatment, of one of the more severe 
forms of scarlet fever with a complication in the throat. 

Cervical Glands. — The glands of the neck are more or less enlarged, 
according to the severity of the infection. This enlargement may in some 
cases be so great as to cause much swelling and distortion of the face and 
neck. The swelling extends at times under the chin from one ear to the 
other as a mass of cellulitis. The tissues of the neck under these conditions 
may, as I have already described to you in speaking of the pathology of the 
disease, suppurate, and this condition, even if it does not produce a fatal 
result from gangrene, may greatly prolong the period of convalescence. 

While the glands are enlarged and tender, the application of hot fomen- 
tations usually gives much relief, as does also in some cases an ice poultice. 
Beyond this I am not in the habit of making any external application. 

Ear. — The middle ear is so closely connected by means of the Eusta- 
chian tubes with the naso-pharynx that aural complications are exceedingly 
common where naso-pharyngeal irritation exists. I shall, therefore, next 
speak of the complications which arise in the ear during the course of 
scarlet fever. 

The symptoms which indicate that a secondary infection of the ear is 
taking place are not always clear, as they may differ much in their manifes- 
tations. We should therefore watch with the greatest solicitude and examine 
with the greatest care the ear during the course of scarlet fever. The symp- 
toms may be active and represented by aural pain and great restlessness. 
On the other hand, there may be no apparent pain, especially in infants and 
young children, who are often unable to indicate the location of the pains by 



THE EXANTHEMATA. 559 

which they are affected. In these cases the symptoms may be merely a 
somnolent condition and occasional attacks of fretfulness. 

According to Professor C. J. Blake, whose advice to me regarding these 
cases has proved invaluable, as soon as an aural complication is detected 
the treatment of the naso-pharynx should be begun. The nose and naso- 
pharynx should be kept as clean as possible. The ear should be gently 
inflated by means of a Politzer bag. Pain should be combated by the 
instillation of a solution of atropine in glycerin and water into the ear (Pre- 
scription 70) and by the application of dry warmth. In addition to this, an 
opiate should, if required, be given internally. 

Prescription 70. 

Metric. Apothecary. 



Gramma. 



R Atropinse sulphatis .... 

Glycerini, 
Aq. destil aa 3 



06 R Atropinee sulphatis gr- i ; 

Glycerini, 

75 Aq. destil aa ^i. 

M. M. 

Sig. — Three or four drops to be warmed and dropped into tlie ear once every three 
hours. 



The congestion should be controlled as far as possible by the internal 
administration of bromide of potassium in small and frequently repeated 
doses. If these measures fail to give relief, and if there is an increase of 
inflammation in the middle ear, as shown by marked swelling and conges- 
tion, especially of the superior posterior portion of the membrana tympani, 
or by a bulging of the membrane, which is seen to be pressed outward by 
the fluid in the tympanum, paracentesis with the knife should be performed, 
always with antiseptic precautions and under good illumination. In the 
early stages of congestion a crescentic incision carried along the superior 
posterior border of the membrana tympani through the congested region, 
and resulting in free hemorrhage, will often cut short an acute process. 
A free incision in the most prominent portion of a bulging membrana 
tympani, by giving a vent to the contained pus, may result in speedy relief 
from both pain and fever, and justifiably forestall the effort which nature 
is making to obtain this relief. In the acute congestive stage, after incision 
of the membrana tympani drainage-wicks made of dry absorbent cotton 
should be applied, and covered at their outer end with a pad of absorbent 
cotton filling the concha. These wicks should be renewed as often as both 
the wick and the cotton pad become saturated. The dressing should be 
kept strictly aseptic. After the paracentesis of the membrana tympani, in 
suppurative cases the ear should be syringed frequently with a weak, wixvm 
solution of bicarbonate of soda, then carefully dried by means of absorbent 
cotton, and, after the first few days, dressed by the insufllation of pow- 
dered boracic acid, while vaseline may be applied to the canal and concha 
to guard against the excoriation of the skin. 

The after-treatment of the middle ear in these cases where there is no 
perforation of the membrana tympani should consist in gentle inflation by 



560 PEDIATRICS. 

means of the air-douche used in accordance with the evidence afforded by 
hearing- tests and by the objective examinations. In cases where there is 
perforation of the membrana tympani with continued suppurative discharge, 
thorough cleansing should be employed. If under this treatment improve- 
ment does not soon take place, the patient should be referred to an aurist. 

I have already referred to the importance of detecting at once a com- 
plication of the ear during the progress of a case of scarlet fever and im- 
mediately treating it. Children are so often rendered deaf by the morbid 
processes resulting from the scarlet fever contagium that it becomes a 
positive, duty for the attending physician to watch the ear as carefully in 
these cases as he would watch the heart in a case of rheumatism. In addi- 
tion to the danger arising from a chronic disturbance of the tissues of the 
ear, you must carefully look for any evidence of the rapid extension of 
secondary infection from the naso-pharynx to the middle ear, and thence 
through the petro-squamosal suture to the cerebral meninges, a series of 
complications which usually proves fatal. 

I recently saw a case in consultation with Dr. Forster which illustrates 
the danger of not treating promptly and thoroughly the complication of 
otitis in cases of scarlet fever. 

A child (Case 242) two and a half years old had been attacked with scarlet fever and 
later with a complicating purulent otitis. "When I saw the child it was lying in a state of 
stupor, apparently induced by pressure on the cerebral blood-vessels of an unusually large 
collection of pus in the middle ear through the petro-squamosal suture. In this case rup- 
ture had taken place in both membranse tympani, and the pus was flowing in large quanti- 
ties from the external meatus. A careful examination by Professor J. O. Green showed, 
however, that the perforations of the membranae tympani were very minute, and the 
cerebral stupor was not relieved until a free opening was made in each tympanum and the 
entire middle ear thoroughly syringed out. Although the symptoms of pressure were 
relieved by these procedures, secondary infection of the cerebral meninges had already taken 
place, and the boy subsequently died of an acute purulent meningitis. 

This case warns us that we should not be misled by the idea that a simple flow of pus 
from the auricle is necessarily sufficient to provide a proper exit for collections of pus in the 
middle ear, and that, unless the case is in the hands of an expert aurist, cerebral pressure or 
purulent meningitis is likely to occur at any time. It also represents a class of cases to 
which I shall refer again when speaking of meningitis, and illustrates one of the secondary 
forms of that disease. 

Kidney. — I have spoken somewhat at length in the earlier part of 
this lecture concerning the albuminuria which is present in the different 
stages of scarlet fever, and also of the different forms of nephritis which may 
occur. What I hope I have impressed upon you is the great importance of 
detecting by means of frequent analyses of the urine the beginning of either 
the milder forms of renal disturbance or the more severe forms of nephritis, 
usually represented by that Avhich is called capsular glomerulo-nephritis. 
If carefully watched for, the appearance of albumin will almost always 
precede the clinical symptoms, and by a still more rigid enforcement of the 
rules which I have laid down as practically governing the treatment the 
further development of a nephritis may be prevented or at least rendered 



THE EXANTHEMATA. 561 

much less pronounced. It is quite frequently the case that a suspicion is 
first aroused of the presence of a nephritis either by vomiting or by oedema 
of the face, especially about the eyes, and commonly occurring during the 
period of desquamation, from the eighteenth to the twenty-fourth day. 
Under these circumstances the urine will be found to be diminished in 
quantity and to contain albumin. The daily amount of the urine may be 
reduced as low as 100 c.c. (3J ounces), or even lower. The microscopic 
examination of the urine does not differ materially from that which results 
from the other forms of nephritis in their early stages, but later you may 
possibly find that fatty casts are less numerous in the nephritis of scarlet 
fever, because there is less fatty degeneration in the renal epithelium. The 
earlier in the course of the disease the symptoms of nephritis appear, the 
more severe, as a rule, will be its type. The extent of the albuminuria 
is of less consequence than the total quantity of the urine. A rapid and 
extensive diminution of the urine is ominous, as it indicates the accumu- 
lation of nitrogenous waste in the blood and the danger of a resulting 
ursemia. The albumin occurring early in the disease is more apt to be 
in large quantities than when it appears first in the third or fourth week. 
Hsematuria is frequently present in this form of nephritis, but ordinarily 
of itself adds little to the gravity of the disease. The oedema of the face 
may be followed by a rapid involvement of the ankles and legs and at times 
may become general. During the course of a general oedema the desquama- 
tion is apt to cease, returning on its disappearance. The oedema may last 
for months or may pass away quickly ; it may be entirely absent, but in 
such cases the nephritis is almost invariably of a light grade. 

At times during the presence of a general oedema serous effusions into 
the pleura may occur. QEdema of the lungs and brain, though rather 
rare, may also take place. Instead of a slow development beginning wdth 
oedema of the face we may have an acute attack, ushered in by fever, 
vomiting, headache, oedema, amblyopia, coma, and convulsions. 

Relapses may occur many weeks after an attack of scarlatinal nephritis, 
and we should watch the case with the greatest care for several months. 
The nephritis of scarlet fever, although it may last for months, has a ten- 
dency in children ultimately to recover, on account of their wonderful re- 
cuperative powers. It is also rare for the renal disease following scarlet 
fever to become chronic. 

Retinitis and amaurosis at times occur during the progress of the 
nephritis in scarlet fever. In these cases of amaurosis it has been noticed 
that, although the loss of sight may be complete, almost always where 
uraemia and amaurosis are coincident there are found no perceptible change 
in the retina, no congestion of the papillae, no increase of intra-cranial 
pressure, and no intense oedema of the brain. The sight, under these cir- 
cumstances, may be recovered completely. 

The alterations in the glomeruli already spoken of not only cause 
the anuria and the uraemia, but also obstruct the renal arteries, as very 

36 



562 PEDIATRICS. 

nearly all the renal blood has to pass through the glomeruli. We find 
in quite a large number of cases of capsular glomerulo-nephritis a rapid 
hypertrophy of the left ventricle. This cardiac complication is not to be 
confounded with the endocarditis which I have already spoken of as 
secondary to the scarlet fever, and which is supposed to be caused by its 
special poison or by the streptococci which I have already described as being 
present in the disease. It is, in fact, not the direct result of the scarlet 
fever, but is secondary to the nephritis, and is, in this sense, tertiary to 
the scarlet fever. We therefore do not find this acute cardiac hypertrophy 
in the earlier stages of scarlet fever, but when a capsular glomerulo-nephritis 
is once established it may take place in so short a period as a week. This 
rapid hypertrophy has usually been observed in children between the ages 
of three and six years, which is of some significance in explaining why this 
hypertrophy should take place so easily. If yoa will recall what I have 
already told you in my lecture on development (Lecture IV., page 122), 
you will understand that between the ages of three and eight years a physi- 
ological hypertrophy of the heart exists, possibly caused by a continuance 
of the aortic narrowing in the neighborhood of the ductus arteriosus, and 
that the heart will be more readily affected by increased blood-pressure at 
that age. This tendency to change in the cardiac muscles is also accentuated 
by the rapid growth of the organ at this period of life. Besides the cardiac 
hypertrophy we may, at times, have an acute dilatation of the heart in these 
cases. This is a serious complication, which must be guarded against, and 
when it occurs must be recognized at once. These cardiac complications 
very frequently recover completely, as it is seldom that any extensive 
changes in the muscles of the heart take place. 

Although the occurrence of sugar in the urine during the course of scarlet 
fever is very rare, yet it is well to examine the urine for this element in cases 
of scarlet fever. By taking this precaution it will sometimes be possible 
to explain some otherwise obscure symptoms which may arise. 



Dr. Zinn, of Bamberg, reports the case (Case 243) of a boy, four years old, previously 
strong and healthy, who was attacked with scarlet fever and diphtheria on January 27. The 
diphtheria was light in form and gradually subsided, but on the thirteenth day from the 
time when the child was seized with scarlet fever an otitis externa appeared, accompanied 
by excessive vomiting and by the rapid development of oedema and ascites. The urine 
showed evidence of nephritis by being lessened in quantity and by containing a large 
amount of albumin and numerous casts and blood-corpuscles. After a few days the more 
dangerous symptoms passed off, and the patient was treated with hot baths and injections of 
pilocarpine. Although the appetite improved considerably, the child's strength did not 
return, and he remained in bed during the whole of March. Early in April, on attempting 
to walk he was found to have paralysis of the right leg, which soon passed off. At this 
time there was a slight trace of albumin in the urine. He then began to show an increased 
action of the heart, and an examination of the urine on the 10th of April showed that the 
specific gravity was 1030 and that it contained a considerable amount of sugar. The total 
amount of urine passed in twenty-four hours was somewhat decreased. The appetite 
at this time was good, the thirst was not noticeably increased, and nothing else abnormal 
was discovered. The child was placed on a diet of meat, milk, eggs, and red wine, and 



THE EXANTHEMATA. 563 

by the 30tli of April there was only one per cent, of sugar in the urine, and by the middle 
of May only one-fourth of one per cent. From this time the child improved in strength 
and was allowed to have a mixed diet. By the middle of June the urine was found to 
be free from sugar and albumin, and the child became as strong and as well as ever. 

I have already told you that very little treatment beyond hygienic 
measures is needed for the mild uncomplicated cases of scarlet fever. 
This can hardly be said of the cases that are complicated with severe 
forms of nephritis, for in these we must act promptly and with great 
judgment. 

We should be careful about using diuretics which might irritate the 
kidney. Acetate of potash is one of the safer diuretics in this complication. 
In the lighter cases a lemonade made with bitartrate of potash will be taken 
well, and will often quickly increase the quantity of the urine, reduce the 
oedema, diminish the albumin, and cause a radical change for the better. 
This lemonade may be made by using 4 c.c. (1 drachm) of bitartrate of 
potash to 473 c.c. (1 pint) of boiling water into which a lemon cut in thin 
s-lices has been dropped. This quantity a little sweetened may be drunk in 
twenty-four hours by a child five years old. 

In severe cases with general oedema and threatening uraemia cathartics 
are rather more certain in their action than diaphoretics and diuretics, and 
are especially indicated where, as is usually the case, constipation is present. 
Podophyllin in doses of 0.006 gramme (^ grain) may be given to a child 
five years old, and repeated a number of times. It usually acts quickly. 
The compound jalap powder in doses of 0.3-0.6 gramme (5-10 grains) may 
also be given where a rapid and decided derivation by the intestine is 
indicated. 

Having provided for the proper movement of the bowels, if the skin is 
hot and dry, and ursemic symptoms, usually represented by anuria, som- 
nolence, amblyopia, and headache, are present, the hot pack, either wet 
or dry, should be resorted to. I prefer in these cases to have the child 
wrapped in a blanket and placed directly in a tub containing water at a 
temperature of 40.5°-43.3° C. (105°-110°^ F.). The child should be kept 
in the water fifteen or tsventy minutes, and even longer if necessary, and 
should then be taken from the wet blanket, enveloped in hot, dry blankets, 
and kept in them until the skin has become moist and reaction has taken 
place. While the child is in the bath, milk can be given to it, and stimulants 
if they are indicated by a weak or an intermittent pulse. 

In addition to this treatment, muriate of pilocarpine in doses of 0.003 
gramme (^ grain) should be given by the mouth to a child of two years, 
and subcutaneously, if desired, to a child five years of age. In these 
cases of threatening uraemia, convulsions sometimes appear quite suddenly. 
Under these circumstances enemata of hydrate of chloral, 0.3-0.6 gramme 
(5-10 grains) dissolved in water, are of value in controlling these nervous 
phenomena. I myself prefer to use a combination of bromide of potash 
and hydrate of chloral, such as you see in this prescription (Prescription 71) : 



564 PEDIATKICS. 



Prescription 71. 



Metric. Apothecary. 

Gramma. 



B Chloral, hydrat. 7 

Potassii brom 15 

Aq. destil 90 



5 B Chloral hydrat i^ii ; 

Potassii brom giv ; 

Aq. destil ^iii. 



M. M. 

Sig. — 3.75 c.c. (1 drachm) in 30 c.c. (1 ounce) of warm water: to be given by enema, 
and repeated in half an hour if needed. 

Where the ascites is extreme, paracentesis abdominis is often of great 
value, not only in relieving the pressure, but also in increasing the action of 
the diuretic, which, perhaps, before was not acting freely. Digitalis is a 
valuable remedy especially adapted to the treatment of the nephritis of 
scarlet fever and to that of the cardiac changes which result from it. By 
the administration of this drug the flow of urine is increased. It is best 
given in the form of a freshly prepared infusion, in teaspoonful doses every 
four hours to a child five years old. Diuretin, 0.3 gramme (5 grains), dis- 
solved in water and given two or three times in the twenty-four hours, has 
proved of considerable value in my cases, and is apparently harmless. 

I speak of special ages, such as five years or two years, merely as a guide 
by which you can judge what the proper doses should be at the other ages. 

In addition to these more common complications of scarlet fever a 
number of secondary infections are at times met with. Thus, cases of 
purpura following or complicating scarlet fever have been reported, and 
are usually fatal. 

An acute inflammation of the joints, usually the larger ones, is not infre- 
quently met with during the course of scarlet fever. This acute synovitis 
is at times apparently either due to or closely connected with rheumatism, 
and may be accompanied by endocarditis and pericarditis. The latter dis- 
ease is, however, rarely met with unless in the later stages of scarlet fever 
in cases where nephritis has developed. These rheumatic cases are usually 
controlled by the administration of salicylic acid. As a rule, they are not 
of long duration, and if effusion takes place in the joints it is serous, does 
not become purulent, and does not give an especially serious prognosis. 

In connection with these cases, either uncomplicated or where the heart 
is also aflected, chorea has sometimes arisen as a complication. 

A more severe form of synovitis, apparently caused by sepsis, may also 
occur during the course of scarlet fever. The effusion in the joints in these 
cases may become purulent and lead to serious and permanent disorganiza- 
tion of the tissues and often to death from general septic infection. 

Besides these acute inflammations of the joints a chronic process at 
times arises, appearing, as a rule, very late in the disease or subsequent to 
it by many months. This inflammation is tubercular in character, and affects 
with especial frequency the hip and knee. Although tubercular, it seems to 
be a late result of the original toxic effect of the micro-organisms of or 
secondarily connected with the scarlet fever contagium. 



THE EXANTHEMATA. 565 

A case wliicli I saw in consultation with Dr. Miller, of Providence, represents so well 
one of the milder forms of what was probably capsular glomerulo-nephritis, and the effect 
of rest in the treatment of the disease, that I shall report it to you. 

A girl (Case 244), five years old, was attacked by scarlet fever of the benign form and 
very mild in its character. After the usual prodromal symptoms the efl9.orescence appeared 
and ran its course, and desquamation became established. At the end of the second week, 
and while the desquamation was still present, the child seemed so well that it was allowed to 
be dressed and about its room. It was also allowed to have its usual food, which included a 
considerable amount of meat. 

On January 4 the child was very irritable during the day, and passed her urine invol- 
untarily in the forenoon. During the afternoon she was feverish, and passed frequently 
small amounts of urine. That night she slept well, but on awaking on the morning of 
January 5 she seemed dull, and was said to be feverish and to have little appetite. 

On January 6 the record stated that she had passed only 90 c.c. (3 ounces) of urine 
in the twenty-four hours. She seemed tired and languid, and there was an cedematous condi- 
tion of the eyes and upper part of the face. She had one normal movement of the bowels. 

On January 7 the total amount of urine passed in the twenty-four hours was 480 c.c. 
(16 ounces). She was given infusion of digitalis and cream of tartar water on this day, and 
placed on a diet of milk. 

On January 8 she seemed better, and passed 480 c.c. (16 ounces) of urine in the twenty- 
four hours. She was then allowed to have an increase in her diet, consisting of broth and 
various kinds of soups. An examination of the urine (Analysis 61) by Professor E. S. 
Wood on this day gave the following result : 

ANALYSIS 61. 

Color Kather pale. 

Eeaction Acid. 

TJrophaein Diminished. 

Indoxyl Increased. 

Urea Diminished. 

Uric acid Increased. 

Albumin Considerable trace. 

Sugar Absent. 

Bile-pigments . . . Absent. 

Specific gravity . . . 1009. 

Chlorides Almost absent. 

Earthy phosphates . Diminished. 

Alkaline phosphates . Diminished. 

Sediment Slight in amount ; consisted chiefly of normal blood-globules, a 

few renal cells, and a few hyaline, fibrinous, blood, and epi- 
thelial casts. The blood-globules and the casts were normal 
in appearance. 

In regard to this examination Professor Wood remarks that the important features 
of the urine were its dilution, the great diminution in the normal salts, especially in the 
chlorides, the considerable trace of albumin, and the blood and casts. The normal character 
of the blood-globules and the comparatively small number of the casts seemed to show that 
only a small portion of the kidney was atFected. At the time of the great diminution in 
the quantity of the urine the tubules were probably nearly completely blocked up. The 
low specific gravity and the great diminution of the urea and chlorides seem to indicate that 
it would need but little additional irritation to produce a marked nephritis. The present 
condition seems to be one of a mild nephritis. 

The general symptoms presented by the child and the disturbance of the kidney shown 
by the examination of the urine made me advise that she should be kept in bed in a warm 
room and placed on a diet exclusively of milk. A w^arm bath was to be given once or twice 



566 PEDIATRICS. 

daily until a larger amount of urine was passed, and 4 c.c. (1 drachm) of infusion of digitalis 
administered four times in the twenty-four hours. 

On January 9 the total amount of urine passed in the twenty-four hours was reduced to 
90 c.c. (3 ounces), and the child was nauseated and vomited a number of times during the day. 

On January 10 she was reported to have had a very restless night and to have been very 
much excited on waking. She had no pain anywhere. Her face continued to be oedematous. 
The total amount of urine passed in the twenty-four hours was 240 c.c. (8 ounces). She 
perspired slightly, and had one large, loose dejection. She so absolutely refused to take 
milk that she was given 103 c.c. (3^ ounces) of beef juice, which was all the nourishment 
that she took on this day. 

On January 11 the face was more oedematous, and she was languid. She'had two large, 
loose, offensive dejections from the bowels, and complained of a burning sensation in the rec- 
tum at the time of the movements. The total quantity of urine was 300 c.c. (10 ounces). 
On this day she was finally persuaded to take milk, and no other food was given to her. 

On January 12 the child seemed brighter and the face was not so much swollen. The 
total amount of urine in the twenty-four hours increased to 540 c.c. (18 ounces), and an 
analysis (Analysis 62) made by Professor Wood gave the following results : 

ANALYSIS 62. 

Color Normal. 

Reaction Acid. 

Urophsein Diminished, 

Indoxyl Increased. 

Urea Slightly diminished. 

Uric acid Increased. 

Albumin A slight trace, and less than on January 8. 

Sugar Absent. 

Bile-pigments .... Absent. 

Specific gravity . . . 1014. 

Chlorides Almost absent. 

Earthy phosphates. . Diminished. 

Alkaline phosphates . Diminished. 

Sediment Considerable in amount, and consisting chiefly of numerous 

blood-globules, a few renal cells, an occasional hyaline and 
blood cast, and an occasional small epithelial cast. 

This specimen showed that improvement had taken place in the condition of the kidney 
since the previous examination, as the albumin had lessened in quantity and the urea had 
increased. 

On January 13 the total quantity of urine had increased to 1410 c.c. (47 ounces). 
The child seemed very well, and was reported to have slept quietly all night. An analysis 
of the urine showed the specific gravity to be 1011. The chlorides, though still much dimin- 
ished, were beginning to reappear, which was a very favorable symptom. 

On January 14 the total amount of urine was 1545 c.c. (51J ounces). The child con- 
tinued to improve in appearance, and seemed bright and welL 

On January 15 the total quantity of urine was 1440 c.c. (48 ounces), and on January 
16 it was 1035 c.c. (34| ounces). 

During the rest of the attack there was no notable change in the total amount of 
urine passed in twenty-four hours. The results of the analyses of the urine which were 
made from time to time showed that there was some process going on beyond a simple 
hypersemia existing in the kidney. The urea remained diminished until the 12th of March, 
when it was found to be increased, and on the 22d of March it was normal. The chlorides 
continued to be diminished until April 7, when they were reported to be normal. The 
specific gravity remained below 1020 until April 13, when it became 1024. A slight trace 
of albumin continued to be found until the following autumn. An analysis (Analysis 63) 
of the urine made September 25 by Professor "Wood gave the following results : 



THE EXANTHEMATA. 



567 



ANALYSIS 63. 

Color Normal. 

Keaction Acid. 

Urophsein. Normal. 

Indoxyl Normal. 

Urea Normal. 

Uric acid Normal. 

Albumin Very slightest possible trace. 

Chlorides Normal. 

Earthy phosphates . . Normal. 

Alkaline phosphates . Normal. 

Specific gravity . , . 1017. 

Sediment Slight, and consisting of a very few normal blood-globules. 

Slight excess of small round cells and of cells like those 

from the neck of the bladder. 

Although a very prolonged search was made for casts, none were found. Professor 
"Wood considered that at this date the kidneys had practically recovered, as they were doing 
perfectly normal work. The blood probably came from the neighborhood of the urethra, 
as there was irritation in that locality. 

In April the child was allowed to have, besides her diet of milk, some broth and bread and 
butter, and in May she was given meat. She was kept in bed until the latter part of March. 

During the course of her sickness various attempts were made to increase her diet more 
quickly and to allow her to be dressed and about the room, but each time when this was 
done she showed symptoms which pointed towards the presence of a renal complication, 
such as a swelling of the eyes and face and a rise of temperature, with resulting nausea 
and loss of appetite. 

This case shows how careful we must be for many weeks and even months to control 
the temperature of the room, the amount of exercise, and the kind of food, where a nephritis 
has complicated a case of scarlet fever. It also shows how entire recovery may take place 
even where the renal irritation is pronounced and unusually prolonged. 

This table (Table 94) gives the record of the total amount of urine 
passed in each twenty-four hours for ninety-two days. 



Days. 
1 
2 

3 , 
4 

5 , 
6 
7 



10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 





TABLE 94. 


C.c. 


Ounces. 


Days. 


90 


3 


21 


480 


16 


22 


480 


16 


23 


90 


3 


24 


240 


8 


25 


300 


10 


26 


540 


18 


27 


1410 


47 


28 


1545 


51^ 


29 


1440 


48 


30 


1035 


34^ 


31 


930 


31 


32 


915 


30^ 


33 


930 


31 


34 


900 


30 


35 


1065 


35* 


36 


1095 


S6h 


37 


1065 


35* 


38 


1140 


38 


39 


1020 


34 


40 



C.c. 


Ounces. 


855 


28i 


900 


30 


1020 


34 


1125 


37i 


1020 


34 


1185 


39* 


975 


32* 


1260 


42 


990 


33 


1155 


38* 


1230 


41 


1230 


41 


1125 


37* 


1185 


39* 


1185 


39* 


1050 


35 


1005 


33* 


990 


33 


1020 


34 


1290 


43 



56S 



PEDIATRICS. 



Days. 

41 . 

42 . 

43 . 

44 . 

45 . 

46 , 

47 . 

48 . 

49 . 

50 . 

51 , 

52 . 

53 . 

54 . 

55 . 

56 . 

57 . 

58 , 

59 , 

60 . 

61 , 

62 , 

63 , 

64 . 

65 . 

66 . 



C.c. 
1170 
1215 
1020 
1110 
1095 
1425 
1305 
1125 
1230 
1125 
1155 
1080 
1005 
1080 
1200 
915 
1215 
1335 
1245 
1095 
1040 
1050 
975 
935 
990 
1050 



TABLE 94. 
Ounces. 



39 

40^ 

34 

37 

36^ 

47^ 

43J 

37^ 

41 

37^ 

38^ 

36^ 

33^ 

36^ 

40 

30J 

40^ 

44^ 

4H 

36J 

35 

35 

32^ 

31^ 

33 

35 



■Continued. 
Days. 
67 . . 



69 
70 
71 
72 
73 
74 
75 
76 
77 
78 
79 
80 
81 
82 
83 
84 
85 
86 
87 



90 
91 
92 



C.c. 


Ounces 


900 


30 


1275 


42J 


1230 


41 


1140 


88 


1275 


^^ 


1185 


39^ 


1230 


41 


1380 


46 


1275 


42J 


1260 


42 


1230 


41 


1215 


40^ 


1230 


41 


1140 


38 


1230 


41 


1305 


43i 


1230 


41 


1170 


39 


1200 


40 


970 


29 


735 


24^ 


1235 


34^ 


930 


31 


885 


29J 


885 


29^ 


1065 


35J 



This table (Table 95) shows the record of the total amount of milk 
taken by the child in each twenty-four hours during thirty-one days. Milk 
was her exclusive diet during these days, and although, as I have already 
told you, in the beginning of her sickness she disliked and refused to take 
milk, she was, nevertheless, persuaded to take it, and finally did so without 
resistance. The table is instructive as showing the amount of milk which 
is sufficient for nourishment for a child of this age. 



Days. 
1 . . . . 


C.c. 
.... 630 


TABI 

Ounces. 
21 
48 
51 
48 
48 
48 
48 
42 
42 
42 
42 
42 
48 
45 
45 
45 


E 95. 
Days. 

17 

18 

19 . . 


C.c. 
.... 1260 
.... 1620 
.... 1530 


Ounces. 
42 


2 . . 


.... 1440 


54 


3 . . . . 


.... 1530 
.... 1440 


51 


4 . . . . 


20 

21 

22 

23 .... . 

24 

25 

26 

27 

28 

29 

30 

31 ... . 


.... 1440 
.... 1530 
.... 1530 
.... 1530 
.... 1530 
.... 1620 
.... 1620 
.... 1620 
.... 1620 
.... 1620 
.... 1620 
. . . 1620 


48 


5 


.... 1440 


51 


6 . . . . 


.... 1440 


51 


7 . . . . 

8 . . . 


.... 1440 
.... 1260 


51 
51 


9 . . . . 

10 ... . 

11 ... . 


.... 1260 
.... 1260 
. , . 1260 


54 
54 
54 


12 ... . 

13 ... . 


.... 1260 
.... 1440 


54 
54 


14 ... . 

15 ... . 


.... 1350 
.... 1350 


54 
54 


16 ... . 


.... 1350 









Case 24/ 




I.— Before treatment. 




II.— After treatment. 
Scarlet fever. Nephritis ; enlargement of the hean. 



THE EXANTHEMATA. 569 

This boy (Case 245, I.) whom you see here in the convalescent ward 
is an illustrative case of scarlet fever complicated by a probable capsular 
glomerulo-nephritis and a resulting cardiac enlargement. 

He is seven years old, and entered the hospital on July 28. His mother is living and 
well, and states that his father died of Bright's disease. The child is said to have been well 
until eighteen months ago, when he had an attack of scarlet fever, mild in form and not 
accompanied by any severe symptoms. In the latter part of the attack his temperature rose, 
and he began to have dyspnoea and dropsy. Since that time he has been slowly but steadily 
growing worse. As you see, he has extensive cedema of the face, chest, arms, abdomen, 
and legs. He is somewhat cyanotic, and his breathing is so much affected that he is unable 
to lie down, the orthopnoea compelling him to be supported in a semi-recumbent position. 
On closer examination you see that there is a slight puffiness about both eyes, that there is 
a yellow tinge of the conjunctivae, and that the lips and tongue are cyanotic. The extremi- 
ties are cold to the touch, and their skin pits readily on pressure. The skin of the whole 
body is dry and harsh and in certain portions is covered with fine scales. On the inner side 
of the left leg and on the outer side of the right leg are some old scars, apparently resulting 
from a previous scarification performed for the reduction of the anasarca. In addition to 
the oedematous condition of the walls of the abdomen, a distinct fluctuation is found on pal- 
pation, showing that there is fluid in the abdominal cavity. An examination of the lungs 
shows that there is dulness over both bases behind, and over these areas of dulness, as well 
as over the whole front of the chest, fine moist rales can be heard, indicating an (edematous 
condition of the lungs. On examining the heart, I find that its impulse is most distinct 
in the sixth interspace a little outside of the mammary line. The area of cardiac dulness 
extends from the second rib on the left to 2.5 cm. (1 inch) to the right of the sternum, in 
an area corresponding to the third interspace and fourth rib. The dulness then extends to 
the left across the sternum to a point 2.5 cm. (1 inch) outside of the mammary line and as 
low as the sixth interspace, corresponding to the cardiac impulse. A loud systolic murmur 
can be heard over the region of the cardiac impulse, and is transmitted so that it can be 
heard in every part of the thorax. The total amount of urine in twenty-four hours has 
varied from 900 to 1050 c.c. (30-35 ounces). An analysis (Analysis 64) of the urine gives 
the following results : 

ANALYSIS 64. 

Color Darker than normal. 

Specific gravity , 1013. 

Eeaction .... Acid. 

Urophasin- . . . Diminished. 

Indican .... Increased. 

Chlorides . . . Diminished. 

Albumin . . . y% per cent. 

Sugar Absent. 

Sediment . . . Very slight and flocculent. Microscopic examination shows numerous 
short hyaline and granular casts of medium diameter and occasion- 
ally of small diameter ; an excess of renal epithelium ; considerable 
abnormal blood ; an occasional white corpuscle ; one or two blood- 
casts, many hyaline and granular casts, with one or more renal cells 
adherent ; occasional fatty renal cells and casts with a few fat-drops 
adherent. 

On entering the hospital yesterday he had a slight diarrhcea. You see that to-day he is 
unable to lie down with comfort, on account of the dypsnoea arising from an accumulation 
of fluid in the abdomen. The legs are also very much swollen and edematous. His face is 
somewhat pufly. The cyanosis is so marked and the child is in so much distress that it is 
evident that immediate relief should be given not only to the general symptoms, but also to 



570 PEDIATRICS. 

the great tax which is being imposed upon the already disabled heart. Unless some relief to 
these symptoms is given, it is very likely that he will die suddenly from heart-failure. I shall, 
therefore, withdraw a certain amount of fluid from the abdominal cavity, which will, I think, 
be followed by considerable relief to the dypsnoea. You see that I have first assured myself 
that the bladder is empty, have then had the child supported on the side of the bed with the 
legs apart, have introduced a trocar into the median line of the abdomen just below the 
umbilicus, and have withdrawn 480 c.c. (16 ounces) of clear, yellowish fluid. You will 
notice that the child already breathes with much greater freedom and that the cyanosis is 
decidedly diminished. 

This case illustrates some of the points in the pathology and clinical symptoms of scarlet 
fever to which I have already referred. Of course at as late a stage of the disease as that 
when the boy entered the hospital it would be impossible to make a definite diagnosis as to 
the condition of the kidney and heart which may have existed at an earlier stage. It is 
possible that during the stage of efilorescence an endocarditis such as might complicate the 
earlier symptoms of scarlet fever may have befen present and may have been followed by a 
pathological lesion of the valves. The history of the case, however, states that the course 
of the scarlet fever was a mild one in its early stages, and that whatever complications 
followed arose at a later stage of the disease, during desquamation. It would seem probable, 
therefore, that the symptoms of oedema and cyanosis which appear in this later stage of the 
disease were caused by a disturbance of the kidney. As I have already told you, a renal 
complication is most common in the later stages of scarlet fever. The physical examination 
made when the child entered the hospital showed that there was a complication of the heart, 
represented by cardiac enlargement and a mitral systolic murmur. The examination of the 
urine shows us that it is probable that there are organic changes in the kidney as well as in 
the heart, although we cannot say definitely that such conditions as we find in the urine have 
not been produced by a cardiac lesion followed by passive congestion of the kidney. There- 
fore, although we cannot decide without a post-mortem examination whether both kidney 
and heart are aflected, we can at least suppose that the following sequence of complications 
has resulted and has produced the present clinical symptoms. 

The child had scarlet fever in a mild and apparently uncomplicated form until he reached 
the stage of desquamation. During the latter part of this stage a lesion of the kidney, 
presumably of the capsular glomerular form, occurred, and, owing to the increased blood- 
pressure which finally resulted from the changes in the kidney, hypertrophy of the heart, 
presumably followed by dilatation, appeared. If I have correctly read this sequence of 
lesions, we have, then, cardiac enlargement secondary to a renal disease and tertiary to the 
original scarlet fever contagium. 

The prognosis in this case is very unfavorable. Although we know that in children dila- 
tation of the heart may be entirely recovered from, yet as long as this <;ondition exists there 
is danger of sudden death from cardiac failure. Where the cardiac dilatation results from 
extensive disease of the kidney, especially in the form which we most commonly meet with 
in scarlet fever, capsular glomerulo-nephritis, the chances are that this failure will take 
place before the nephritis has been recovered from when a patient has been reduced to such 
a degree as is the case with this boy. 

The treatment should be absolute rest, so as not to tax the muscles of the heart more 
than can possibly be avoided. To relieve the intra-abdominal pressure, which augments the 
oedema of the lungs and interferes with the action of the heart, paracentesis of the abdomen 
should be performed, as I have just shown you. Hot baths should be given to increase 
the action of the skin, laxatives to relieve the congested condition of the kidneys, and non- 
irritating diuretics, such as acetate of potash and digitalis, are indicated. Nitro-glycerin 
is valuable where the action of the heart at any time becomes suddenly feeble and 
irregular. 

(Subsequent history of the case.) For the next few days after paracentesis of the 
abdomen the child improved greatly, the dyspnoea ceased, the urine became of a better color 
and increased in amount, the cyanosis grew less, and, although the pulse was still small and 
feeble, the child showed great general improvement. In the course of a month the oedema was 
so much reduced that the child looked like a different person (Case 245, II., facing page 569). 



THE EXANTHEMATA. 571 

He was able to lie down with comfort, slept well, his appetite returned, and at one time he 
could even be moved about the ward in a wheel^chair. Some weeks later the cardiac symp- 
toms returned, and he again began to have oedema and ascites, cyanosis and orthopncea. The 
urine, as you see in the table (Table 96), varied considerably, but at no time did it show the 
great lessening which is found in cases of threatening ursemia. The s^'mptoms were, indeed, 
mostly those of a crippled heart. At one time the temperature, without any assignable 
cause, rose to 41.1° C. (106° F.), and somewhat later it became subnormal. On September 
4 the ascites had increased to such a degree that paracentesis of the abdomen had to be again 
performed. 

On September 8 the oedema increased, and the urine was reduced to 450 c.c. (15 ounces). 
Diuretin was given in doses of 0.6 gramme (10 grains), which increased the flow of urine 
to 1230 c.c. (41 ounces). The diuretin given in these "doses once or twice a day for some 
time continued to act successfully. 

In October the action of the heart grew still weaker, the oedema of the lungs increased, 
and, although there had been a general improvement, the child grew progressively weaker 
during November. Early in December he was attacked with vomiting, had a weak and 
rapid pulse, gradually failed in strength, and on the 21st of December died suddenly. No 
autopsy was obtained. 

The total amount of urine in this case, measured daily from July 29 to September 15, 
was as follows : 

TABLE 96. 

{Total amount of urine passed in ticenty-four hoicrs during thirty-one days in a case of scarlet 
fever complicated by nephritis and resulting in cardiac dilatation.) 

Date. C.c. Ounces. 

July 29 . . . . 1440 48 

July 30 1230 41 

July 31 810 27 

August 1 810 27 

August 2 900 30 

Augusts 600 20 

August 4 1320 44 

Augusts 990 33 

August 6 630 21 

August 7 510 17 

August 8 510 17 

August 9 840 28 

August 10 1020 34 

August 11 1020 34 

August 12 720 24 

August 13 1020 34 

August 14 690 23 

August 22 840 28 

August 23 990 33 

August 28 600 20 

August 29 750 25 

August 30 480 16 

August 31. 600 20 

September 1 840 28 

September 2 480 16 

September 3 900 30 

September 4 ' 540 18 

September 7 450 15 

September 10 1230 41 

September 14 660 22 



September 15 750 



572 



PEDIATEICS. 



CHAKT 16. 



Malignant Form. — I have told you in the beginning of this lecture 
that there are two distinct forms of scarlet fever, and I have spoken at 
length of the benign form, with its variations and complications, and its, 
as a rule, favorable prognosis. I shall have but a few words to say of the 
malignant form of scarlet fever, for it is almost without exception fatal, 
and is very rare in comparison with the benign form. Malignant scarlet 
fever appears to attack those individuals who have a 
predisposition to be profoundly affected by the scarlet 
fever contagium. In these cases we see healthy chil- 
dren attacked with intense headache, high fever, deli- 
rium, sometimes coma, and death follows usually in 
two or three days. A case of this kind was seen by 
me in consultation with Dr. Emerson, of Concord, and 
represents so well the conditions which are present in 
these cases of scarlet fever that I shall report it to you. 



A girl (Case 246), eleven years old, was perfectly well and 
strong and had no other diseases up to January 10. In the mid- 
dle of the day she felt very ill and vomited. Her pulse was 150, 
temperature 40,2° C. (104.5° F.). The pharynx and tonsils were 
much reddened, but there was no exudation or membrane to 
be seen. An efflorescence of a scarlatinal type appeared on the 
chest in the afternoon. The vomiting continued through the 
night and up to the morning of January 11. The child was 
conscious, but dull, The pulse was 150, and the temperature 
was 40.5° C. (105° F.). At 4 p.m. the face became puffy, and the 
efflorescence was well marked on the body and extended to the 
extremities. The child was wandering and stupid, and the tem- 
perature rose to 42.2° C. (108° F.). The extremities became 
livid, and the vomiting began again. At 6.30 p.m. the tempera- 
ture, after the internal administration of various remedies, was 
found to be 41.1° C. (107° F.), and at 10 p.m. 41.1° C. (106° F.), 
and the pulse 160, weak and difflcult to count. At 6 a.m. on 
the 12th, forty-eight hours from the appearance of the first 
symptoms, the child died. 

The case was a perfectly hopeless one from the beginning, as 
every method of treatment which could be thought of was tried 
and proved absolutely fruitless. Tub bathing with water at 
different temperatures, and finally sponging with ice-water, had 
no effect whatever on the temperature or the general symptoms. 



jl?fzj/S o/Z^isGase, 


F 


1 2 


3 


c 


M 


JE M E 


¥ 


41.6° 

41.1° 

40.5° 

40.0° 

39.4° 

38.8° 

,38.3° 

37.7° 

37.2° 
37.0° 
36.6° 

36.1° 

35.5° 

35.0° 


lU/" - 


j 


V 


lf»«\0 - 


/ 




IAaO _ 


... ^.. 










irJ9o - 






ini® - 


1 










lUO" " 






NORML . 


I- 


.^- 


yyv 






opfi . 




!! 


95° = 




4 


150 - 

\Af\ 


"~a7 


r 


-J 
CL 






lao 






lOA 






110 - 

II I(V> . 










50 - 






80 
70 
60 


1 








i 


L 



Malignant form of scarlet 
fever. Girl, 11 years old. 



This chart (Chart 16) shows the temperature from the time of the attack 
to within a few hours before death. 



THE EXANTHEMATA. 573 



LECTURE XXVI. 

THE EXANTHEMATA.— (Concluded.) 

Measles. — Kubella. 

MEASLES (Rubeola). — Measles is one of the most common diseases of 
childhood^ and has been known for many centuries. It is an acute infectious 
disease, evidently caused by a specific micro-organism. It is characterized 
by lachrymation, photophobia, coryza, cough, a papular efflorescence, and 
a slight desquamation. The micro-organism which produces measles has 
not yet been determined. It is supposed to find its vehicle in the tears, and 
in the secretion of the throat and nose, and possibly to exist in the blood. 
Its tenacity for clothing, thus continuing as a fresh source of infection, is 
mild in comparison with that of scarlet fever. It is very infectious, and 
in some communities is at times exceedingly fatal. This was the case in 
the epidemic of 1873 in the Fiji Islands, where it had not occurred for a 
long time ; it spread rapidly, and caused two thousand deaths, of which 
sixty-seven per cent, were in children under five years of age. The high 
mortality in measles is, as a rule, not caused by the measles itself, but by its 
complications. The epidemics of measles, as I have already told you in 
comparing the disease with scarlet fever, spread rapidly and appear to have 
an element of periodicity. This has been well exemplified here in Boston, 
in the crowded districts at the North End, where in certain years large 
numbers of children are affected, and where in the succeeding years the 
disease appears only sporadically. Measles can occur three or four times in 
the same individual : this recurrence was one of the peculiar features of the 
epidemic in Boston in 1880. It may attack young infants, but is rare 
nnder six months. After the sixth month, and especially during the first 
year, the susceptibility to the disease is increased, and we meet with the 
greatest number of cases between the first and the fifth year. The suscep- 
tibility to measles appears to lessen as puberty is approached. It is some- 
what rare in adult life, though the fact of its attacking large numbers of 
adults was also a peculiarity of the epidemic of 1880 in Boston. 

Measles is an extremely infectious disease, the contagium apparently 
passing from one individual to another after a very short exposure, and often 
without any direct contact, as by transmission through clothing or by the 
hands. It is most infectious in the beginning of the attack, and the infec- 
tion may be transmitted three or four days before the efflorescence appears 
on the skin. There seems to be much less liability for the transmission 
of the disease during the stage of desquamation tlian is the case in some 
of the other exanthemata, such as scarlet fever and variola, the meims of 



574 PEDIATRICS. 

transmission corresponding more to that of varicella. In speaking of scarlet 
fever I have already referred to the case (Case 234, page 533) of the little 
girl who, although exposed to the scarlet fever infection in the beginning 
of the disease, did not contract it, but in the following year, when exposed 
for a shorter time to the contagium of measles, was immediately infected by 
that disease. The following cases which I shall report to you will be inter- 
esting and instructive as examples of how the transmission of the contagium 
of scarlet fever can be prevented by treatment, and will also illustrate the 
high degree of the infection in the early stages of measles. 

A boy (Case 247) who was in my ward at the Children's Hospital was attacked with 
scarlet fever. 

I had him removed to the contagious ward and placed under the care of a special 
nurse, who had orders to carry out the most precise antiseptic treatment. The directions to 
the nurse were that she should apply an ointment to the child, rubbing it into the skin 
thoroughly from the head to the feet twice daily. The child was also to be bathed twice 
daily with a solution of corrosive sublimate, 1 to 10,000. The nurse was cautioned not to 
allow her clothes to touch the boy's bed. 

During the early stage of this boy's desquamation a second boy (Case 248), who 
occupied the bed in the general ward next to* the bed from which the first boy had been 
removed, was attacked with sore throat, vomiting, and fever. I had already paid my visit 
for the day, and my house officer, thinking the case was probably one of scarlet fever 
contracted from having been in such close proximity to the bed from which the first boy 
was taken, had the second boy removed to the contagious ward and placed in the same 
room with the first boy. On the following morning I found that the second boy did not 
have scarlet fever, but had measles. I immediately had the second boy removed to 
another room, and he was carefully watched for a week, supposing that having passed the 
night with the first boy, who was in the most infectious stage of scarlet fever, he might 
have contracted scarlet fever. A week passed, and he evidently had escaped infection by 
the scarlet fever contagium. 

Ten days later the boy who had scarlet fever was attacked with measles, presumably 
contracted during the night from the boy who was his room-mate in the early stage of his 
attack of measles. 

These two cases apparently show — first, that scarlet fever, even during its most infec- 
tious stage, can be prevented from spreading by thorough and constant disinfection ; second, 
that measles is highly contagious in its early stages. 

Pathology. — Beyond the morbid conditions which appear on the skin 
and on the mucous membrane of the throat, there is no especially character- 
istic pathology of measles. 

Neumann has studied the pathology of the skin in measles by means of 
specimens which were hardened in a dilute solution of chromic acid and 
colored with carmine, hsematoxylin, and picro-carmine. The pathological 
changes were found to be almost entirely confined to the glands of the skin 
and to the blood-vessels. About the walls of the blood-vessels, principally 
in the upper layers of the cutis, were found collections of round cells which 
in crowded masses surrounded the loops of the blood-vessels even in the 
papillae. The blood-vessels themselves were dilated and full of blood. 
The coils of the sweat-glands, as well as the excretory ducts, were enveloped 
in accumulations of round cells, while the neighboring tissues were filled 



THE EXANTHEMATA. 575 

with these cells. These collections of cells were always situated outside 
of the walls of the glands. The sebaceous glands presented like changes. 
The hair-follicles showed rounded protuberances which corresponded to the 
points of insertion of the erectores pilorum, and which were probably caused 
by contraction of these muscles. In the muscles themselves there were to 
be found, between the cells proper of the muscular tissue, scattered round 
cells, which showed the participation of the muscular tissue in the inflamma- 
tory process. The hair-follicles, in the same manner as the sweat-glands, 
were seen to be surrounded in their entire length by collections of round 
cells, which were more numerous in the lower than in the upper part of the 
skin. We therefore see that in measles the pathological process in the skin 
affects chiefly the blood-vessels and glands, while the tissue proper of the 
skin, as well as of the epithelium, presents no marked changes. 

From the fact that in measles the pathological processes of the disease 
are situated more particularly around the blood-vessels and cutaneous glands, 
it may be assumed that the infectious material of the malady, whatever its 
nature, is eliminated from the system through these channels. 

In addition to the pathological lesions which occur in the uncompli- 
cated cases of measles, there is almost always associated with the catarrhal 
condition of the mucous membrane of the upper air-passages a catarrh of 
the larger bronchi. One of the most common complications of measles is 
pneumonia ; this is usually a broncho-pneumonia, lobar pneumonia being 
comparatively rare. 

In some cases an inflammation of the smaller bronchi accompanied by 
pulmonary collapse occurs. The bronchial glands are apt to be swollen if 
the secondary infection is a severe one. According to Osier, a swelling of 
Peyer's glands is not uncommon, and may be accompanied by a hypersemic 
condition of the mucous membrane of the gastro-enteric tract. 

Although a secondary infection of the ear has been considered rather 
distinctive of scarlet fever, this complication has in my experience arisen 
also quite frequently in measles. When the ear is affected in measles there 
is a congestion of the middle ear. When the onset of the preliminary 
congestion occurs in connection with the inflammation of the nasal and 
naso-pharyngeal mucous membrane, it consists of a simple, general, acute 
congestion of the middle ear, accompanied in the beginning with serous 
exudation, and later with a rapid thickening of the membrana tympani in 
connection with the inception of the suppurative process. When, on the 
other hand, the preliminary congestion is coincident with or follows the 
efilorescence on the face, the congestion is primarily in the upper portions of 
the membrana tympani as the result of a suspension of vaso-motor inhibi- 
tion. Under these conditions there is a congestion of the manubrial plexus, 
of the superior and posterior portions of the membrana tympani, and of the 
corresponding portions of the inner end of the external auditory canals. 

In addition to this more common condition, a general congestion of tlie 
membrana tympani is found during the stage of efilorescence, and is likely 



676 PEDIATRICS. 

to be more severe in its- type than that which occurs during the prodromal 
stage of measles. 

The inflammation of the middle ear accompanying measles is more likely 
to leave behind such trophic changes as thickening of the tympanic mucous 
membrane with the formation of adhesions than is scarlet fever. " 

During an attack of measles, and subsequent to it, the tissues show an 
especial vulnerability to infection by the bacillus of tubercle. The tuber- 
cular infection may be represented by the lesions of a general miliary 
tuberculosis or by those of especial tissues, such as of the cervical and 
bronchial glands, the joints, the ear, and, most commonly of all, the lung. 
In the latter instance the lesions are usually those of a tuberculous broncho- 
pneumonia. 

Incubation. — The time of the incubation of measles may vary very 
much, and may cover a period of two or three weeks ; the usual time, how- 
ever, is ten days. 

Symptoms. — Prodromata. — The prodromal stage varies in length, but, 
reckoning ten days as the usual time for the stage of incubation, the pro- 
dromal stage may be considered to last from two to three days, and in some 
cases four days. In this stage we have in typical cases of the disease symp- 
toms distinctive of measles. The invasion is characterized by severe 
catarrhal conditions affecting the nose (coryza), the eye (lachrymation), and 
the throat and upper air-passages (cough). In the first twenty-four hours 
the temperature rises to 38° or 39° C. (100.4° or 102.2° F.), and often to 
40° C. (104° F.). The height of the temperature on the first evening is a 
fair indication as to the severity of the coming disease. Thus, a tempera- 
ture of 40.5° C. (105° F.) indicates a severe case. An important point to 
be noticed regarding the prodromal symptoms is that after the first twenty- 
four hours there is in a large number of cases a remission in the temperature, 
which goes down, perhaps, to 37.5° or 37° C. (99.5° or 98.6° F.), and 
remains down for about twenty-four hours, when it again rises. The cough, 
coryza, and lachrymation, which appear early in the prodromal stage, do not 
abate, but rather increase, during this remission of the temperature. This 
is an important point to remember, as the child who seems quite sick and 
loses its appetite while the temperature is high during the invasion of 
the disease, seems brighter and has a return of appetite on the second day 
when the temperature is lower. This peculiarity of the prodromal stage is 
often misleading both to the parents and to the physician, who, because the 
child appears so much better, are led to believe that one of the infectious 
diseases is not developing. In infants and young children the prodromal 
stage may begin with a convulsion, but this is unusual, and if it occurs it is 
not, as a rule, particularly severe, and does not necessarily make the prog- 
nosis more grave. Headache in the prodromal stage is quite frequent; 
vomiting is rather rare. The tongue is usually furred, and the mucous 
membrane of the throat towards the end of the second day, and before the 
efflorescence has appeared on the skin, shows a condition which is very 



THE EXANTHEMATA. 577 

similar to that which is about to appear on the skin. These lesions^ which 
are especially pronounced on the soft and the hard palate, are represented by 
papules or macules of a dark-red and later purplish-red color, of different 
sizes, and considerably larger than the punctate macules which I have 
described in speaking of the throat in scarlet fever. These papules may 
sometimes be found to have coalesced in some parts of the fauces. The 
mucous membrane between the lesions is comparatively normal in color, 
though there may be a slight hypersemia of the entire throat. This hyper- 
emia, however, is not nearly so intense as is seen in the throat in scarlet 
fever. After the remission of the temperature, which I have already 
described as taking place on the second day, the temperature on the third or 
fourth day again rises. 

Efflorescence. — At the end of the third day or at the beginning 
of the fourth day — that is, the thirteenth or fourteenth day from the time 
when infection took place — an efflorescence appears on the skin. The efflo- 
rescence usually reaches its maximum in about thirty-six hours, this being 
a more constant number than the other figures which I have given you ; 
that is, it is about the fifteenth day from the date of infection. The stage 
of incubation is rather more constant than the stages of prodrome and efflo- 
rescence, the latter two varying as to their length, but together amounting 
to five or six days. 

When the efflorescence appears on the skin it consists commonly of small 
macules or papules on a slightly reddened base, which first appear on the 
face. As the disease progresses, these lesions extend to the neck and chest, 
and in the latter locality are, especially in the beginning, of a delicate pink 
<X)lor, the form of distribution in some cases being crescentic. The efflores- 
cence then rapidly extends to the rest of the body and to the extremities. 
It is usually more pronounced on the face, where the papules are apt to 
coalesce, and where an oedematous condition of the tissues, especially around 
the eyes and nose, usually occurs. The eyes are swollen and partially 
€losed, and the conjunctivae are reddened. Photophobia at this time is pro- 
nounced. The efflorescence may also appear on the scalp. The efflorescence 
remains well marked for from one to tw-o days, and while it is at its height 
the temperature reaches its maximum, and remains high for two or three 
days, corresponding to the intensity of the efflorescence. It then rapidly 
falls, and reaches the normal point in about tw^o days more, — that is, there 
appears to be often a distinct crisis in the disease. During the period 
of efflorescence, when the temperature is still raised and the efflorescence is 
at its maximum, it is usual to have, in addition to the symptoms of cough, 
coryza, and lachrymation, a slight disturbance of the intestines, represented 
by small, frequent, loose discharges, apparently arising from irritation of 
the rectum and descending colon. This condition is seldom a serious one, 
and no especial attention need be paid to it unless it should continue for 
some days, or after the maximum of the temperature and efflorescence has 
been passed for a day or two. 



578 PEDIATRICS. 

Desquamation. — The desquamation is usually furfuraceous in charax> 
ter,— that is, the epithelium is cast off in fine flakes, and is thus distin- 
guished from the large lamellar flakes occurring during the period of 
desquamation in scarlet fever. The desquamation begins in the order in 
which the efflorescence came out, — namely, first on the face and later on the 
chest. The furfuraceous character of the desquamation is especially notice- 
able on the sides of the nose. The disease usually runs its entire course in 
three weeks. 

Prognosis. — The prognosis of measles, as a rule, is good, but this 
depends almost entirely upon whether the disease is free from or accom- 
panied by complications. 

Diagnosis. — In order that you should xmderstand how difficult it some- 
times is to diagnosticate measles, you must recognize that it is one of the 
most variable diseases with which we have to deal. During epidemics of 
undoubted measles cases arise which differ materially from the disease as it 
appears in its typical form, yet these cases, by producing the typical form in 
other individuals, prove that they are all caused by the same contagium. 
In like manner certain epidemics may be characterized by irregular forms 
of the disease, and, as true measles can occur a number of times in the same 
individual, the recognition of a sporadic case is often impossible. As in 
other diseases of the skin, we should recognize measles not by any particu- 
lar dermal lesion, but by the peculiarities of the prodromal symptoms, the 
general course and location of the efflorescence, the time of the maximum 
of the efflorescence and temperature, and the character of the desquamation. 
Thus, a prodromal stage of three or four days, characterized by catarrhal 
symptoms of the eyes, nose, and upper air-passages, and a papular efflo- 
rescence appearing first on the face, differentiate the disease at once from 
variola, varicella, and scarlet fever. 

Treatment. — The treatment of measles is essentially symptomatic. 
There is no known means of producing immunity from the disease or of 
shortening its course. It is a self-limited disease, and the treatment should 
be directed to protecting the organs which are most likely to be attacked by 
complications. Bearing in mind that the eye, the nose, and the throat are 
affected in the prodromal stage, that later the skin is in a very sensitive 
condition, and that the lung is frequently the seat of some complication, we 
should direct our treatment especially to the protection of these organs. 

The child should be placed in a room kept at an equable temperature, 
20°-21.1° C. (68°-70° R), and well ventilated. The room should be 
darkened, and the eyes should be protected from light during the whole 
course of the disease. Unless this precaution is taken, the eyes are often 
seriously affected for many months after the measles itself has disappeared. 
The child should be kept in bed until the temperature has been normal for 
a few days, the efflorescence has faded entirely, and the desquamation has 
almost ceased. 

The diet during the period of the height of the temperature should be 



THE EXANTHEMATA. 



579 



soup, milk, and bread. Later, when the temperature is normal and desqua- 
mation has begun, the child can gradually have its diet increased, until 
by the thiixl week from the beginning of the attack it is having its usual 
food. 

The cough, which is very troublesome at times, does not, as a rule, require 
any special treatment, as it will of itself in most cases pass off in a few 
days. AATiile it continues it can be treated with some simple mixture, such 
as camphorated tincture of opium in cold water in doses of 0.3-0.6 c.c. 
(5-10 minims), to allay the irritation in the throat. 

For the irritation of the nose I have found that atomizing the nares 
with some simple refined oil, such as oleum petrolatum album, is useful. 
During the invasion of the disease, however, these catarrhal symptoms 
are exceedingly difficult to control by any treatment whatever. 

As at times there is great irritation of the skin during the period of 
efflorescence, this powder (Prescription 56, page 466) should be applied 
thickly to the entire body and limbs. In place of the powder some simple 
ointment, such as petrolatum, may prove to be more soothing. 

CHAET 17. 





Days of Disease 




F 


1 


2 


3 


'_J 


5 


6 


7 


8 


9 


10 


c 


107° 
106° 
105° 
104° 
103° 
102° 
101° 
100° 
99° 

NORML 
TEMP 

98° 
97° 
96° 
95° 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


4-16° 

41.1° 

40.5° 

40.0° 

39.4° 

38.8° 

38.3° 

37.7° 

37 2° 
37 0° 

36 6° 

36.1° 
35.5° 
350° 


















































I y 
















/ 


^ 


V 
































1 




/ 


















/ 




1 


































L 


_.. 











y 


1 


























































= 






= 










^ 





Typical measles. 



As a rule, the child should be kept in an equable temperature for at least 
three weeks, and at the end of that time, if the desquamation has ceased, it 
may be allowed to go out of its room, and in pleasant weather out of the 
house a few^ days later. For several months, however, it should be carefully 
protected from sudden changes of atmosphere, as the catarrh of tlio air- 
passages is so likely to leave them in an extremely sensitive condition that 
a very slight irritation may cause its recurrence. 



580 



PEDIATEICS. 



Before the child is allowed to leave its room it should be thoroughly 
bathed from head to foot in hot water. Although the contagium of measles 
has not the same tenacity for clothing as the contagia of variola and 
scarlet fever, yet the room should be thoroughly disinfected after the child 
has left it. This can be done in the same way that I have described to you 
in speaking of scarlet fever ; but the extreme precautions taken in the latter 
disease are not considered necessary for the prevention of the extension of 
measles. If the carpet had not been removed when the child was put into 
the room, it can be taken from the house and thoroughly cleansed before it 
is brought back. The bedclothes and everything that can be washed should 
be thoroughly boiled. The room should be cleansed and the windows should 
be allowed to remain open for several days, as fresh air is one of the best 
means of eradicating the micro-organisms connected with the exanthemata. 

This chart (Chart 17, page 579) shows the temperature as it usually 
occurs in the typical and regular form of measles. 

Before speaking any further of measles I will show you here in the 
isolating ward at the Children's Hospital a case which illustrates so fully a 
typical picture of the regular form of measles that it will be very instructive 
for you to examine it. 



Case 249. 




This little girl (Case 249), six years old, after exposure to measles fourteen days ago, 
was attacked with lachryniation, coryza, cough, and a temperature of 39.4° C. (103° F.). 
On the second day from the beginning of the invasion the 
temperature fell to 37.7° C. (100° F.), but yesterday it rose 
again, and to-day, as you see by the chart, is 40° C. (104° F.). 
Later yesterday afternoon an eflSorescence, papular in character, 
appeared on the face, and, as you see, has now extended to the 
neck and thorax. The disease is now at its height. You see 
the swollen condition of the eyes, nose, and entire face ; also 
the extreme photophobia from which the child is suffering, 
the presence of considerable lachrymation, a continual, short, 
dry cough, and the extensive coryza. You will also observe 

how the papules have coalesced on the face, and are of a darker 

^^1 I color than the widely separated lesions on the chest. 

When you have once seen a case of this kind you will never 
have any difficulty in making your diagnosis in a typical case 

i; of measles at the height of the stage of efflorescence. 
In this next bed is a boy (Plate YII., Case 250, facing page 
551), eight years old, who is at the height of the efflorescence 
: — ._^ of an attack of measles. 

He was seized with the usual prodromal symptoms of 
cough, coryza, and lachrymation five days ago, and to-day has 
the different stages of the typical lesions of measles represented 
on his face and chest. You will notice how the conjunctivas are reddened, and how the eyes, 
nose, and lips are swollen, although this swelling is not so intense as in the case of the little 
girl (Case 249) whom I have just shown you. The efflorescence in this case has run a 
very rapid course, beginning on the face in so intense a form that the desquamation has 
already appeared, although the efflorescence on the chest is in a much earlier stage of de- 
velopment. The papules and macules have, as you see, coalesced on the cheeks and chin, 
while they still appear as large, deeply reddened lesions on the forehead. On the chin and 
neck you will notice the areas of normal skin appearing like white blotches, their boundaries 



Typical condition of the 
face in measles. Female, 6 
years old. 



THE EXANTHEMATA. 581 

determined by the clusters of papules. On the side of the nose you see a slight • desquama- 
tion, which has the furfuraceous character that I have already described to you as typical 
of measles. You will notice that on the chest the papules and macules are much smaller 
in size, are of a much lighter color, and in some places have assumed a crescentic shape. 

This case represents the typical elflorescence of measles, and up to this time has not 
shown evidence of any complication. Both this boy and the girl (Case 249) have received 
no drugs directly for the measles, but have been kept in a dark room to protect the eyes, 
and have been surrounded by an equable temperature. Their food has been milk, broth, 
and bread. 

In this next bed is a boy (Case 251), three and a half years old, who is convalescent 
from an attack of measles. He was exposed to measles on the 2d of the month, and 
had his first prodromal symptoms on the 12th. These prodromal symptoms continued on 
the 12th, 13th, 14th, and 15th, making the prodromal stage four days. On the 16th a 
papular efflorescence appeared on his face, and desquamation began on the 21st of the 
month. 

I merely show him to you as representing the usual time, ten days, in the incubation 
of measles, the rather prolonged prodromal period of four days, the appearance of the 
efflorescence on the face about the fifteenth day from the time of infection and lasting four 
days, and the desquamation beginning five days from the first appearance of the efflo- 
rescence. 

Yaeiatioxs in Type. — I have already referred to the important fact 
regarding the diagnosis of measles, that dnring epidemics and in sporadic 
cases the disease varies mnch in its type, and presents great variations in its 
prodromal stage, in its dermal lesions, in its desquamation, and in its entire 
course. I wish especially to impress this upon you, as it is through a lack 
of appreciation of this fact that the diagnosis of other diseases, such as 
rubella and various forms of erythema, is continually being made where, in 
fact, the disease represents one of the more unusual forms of measles. If 
these variations in measles were better understood, we should not find the 
disease rubella so often diagnosticated. 

At times the stage of incubation of measles varies considerably. It may 
even be extended from the usual ten days to twenty-one days. 

Instead of the usual prodromal stage, certain cases during epidemics of 
undoubted measles show few, if any, prodromal symptoms. 

In this next bed is a boy (Case 252), seven and one-quarter years old, who was attacked 
with the prodromal symptoms of measles on the 9th of the month. These symptoms were 
a heightened temperature of about 38.8° C. (102° F.), a quickened pulse, cough, and coryza. 
On the 10th, 11th, and 12th the child felt perfectly well, had a good appetite and an almost 
normal temperature. On the following day, the 13th, he was found to have the papular 
efflorescence of measles on his face, and a temperature of 38° C. (100.5° F.) in the morning 
and 38.8° C. (102° F.) in the evening. It has been a very mild case, and, as you see, is 
now desquamating slightly. 

I show him to you as representing one of the many variations which arise in measles, 
the variation in this case consisting in the child being perfectly well during the last three 
days of the prodromal stage, and thus showing prodromal symptoms only during the first 
twenty-four hours of the invasion. 

In addition to the usual catarrhal symptoms which I have described, in 
some cases there are vomiting and sore throat. Again, instead of a con- 
siderable elevation of the temperature, it may be scarcely above the normal 



582 PEDIATRICS. 

degree. In addition to the other variations in the course of the ]3rodromal 
stage of measles, cases have been noticed during epidemics of this disease 
where the catarrhal symptoms were absent. Epistaxis of a mild form, and 
not apparently connected with the more severe types of hemorrhage, is 
sometimes met with. I have seen it only occasionally. 

The efflorescence, which in the typical cases usually consists of papules, 
or vesicles and papules, may vary so as to simulate closely a common 
erythema, constituting the form called Iwvis, or may closely simulate a 
papular erythema. Again, the efflorescence may in certain cases be repre- 
sented by minute vesicles or milia, characterizing the form called miliarius. 
Any of these forms may be confluent, but not usually anywhere except on 
the face. There is another form of efflorescence which occurs in measles, 
is rare, and is of a more serious nature than the common benign forms which 
you will meet with ordinarily. This is called the hemorrhagic or malig- 
nant form, and is represented on the skin by small capillary hemorrhages. 
It is often rapidly fatal, and at times appears to be part of a general 
hemorrhagic diathesis represented by epistaxis, hsematuria, and hemorrhages 
from other localities. The temperature in this form is not typical, as it does 
not remit in the prodromal stage, thus depriving us of an important means 
of diagnosis ; but a doubt as to the nature of the disease does not last long, 
as the other symptoms soon become prominent. The more prolonged the 
course of this form the better the prognosis, for if fatal it is usually quickly 
so. It may be complicated by a malignant broncho-pneumonia. 

The efflorescence, besides differing in its form, may vary to a great 
degree in its intensity. Thus, we may have every grade of papule or 
macule, from the smallest to the largest, and varying from a dark purplish 
to a light pink color. In like manner, although the arrangement of the 
efflorescence, especially on the chest, is somewhat crescentic, yet during 
epidemics of undoubted measles this crescentic shape is often absent. In- 
stead of the efflorescence first appearing on the face and then extending to 
the thorax and extremities, we may find in undoubted measles that it begins 
first on the chest or some other part of the body ; or the efflorescence 
may appear on the face and thorax simultaneously. We may also find that 
in certain cases the efflorescence appears first on the abdomen, or on the 
thighs, and yet the presence of other typical and undoubted cases of measles 
in the vicinity or in the same house assures us that we are dealing with 
the same disease. The efflorescence instead of lasting for a number of 
days may be evanescent and may subside within twenty-four hours. The 
entire absence of efflorescence is said to occur in some cases, but must be 
considered very rare, and its possibility has been doubted. 

The desquamation of measles is of so light a grade that it is not sur- 
prising that in some cases no desquamation whatever is detected. Cases 
where desquamation occurs without efflorescence are highly improbable, 
although such have been reported. 

During certain epidemics of undoubted measles cases have not infre- 



THE EXANTHEMATA. 583 

quently been noted where the post-aural and cervical glands were en- 
larged. 

There is a form of measles, called the recurrent, which is closely allied 
to relapsing fever. The main characteristic of this form is the high fever. 
The temperature will sometimes be raised for five or six days, will then 
become normal for seven or eight days, and will then rise again with a re- 
currence of the symptoms. This is a very unusual form, and one which 
needs merely to be mentioned here. It is accompanied by the general 
symptoms connected with the nose, eye, and bronchi which are met with 
in the typical form of measles. 

Relapses have been reported to occur in measles, but they must be very 
uncommon. I have never met with such cases. 

In reviewing the pictures which I have endeavored to give you of these 
variations, it must be evident to you that, although in the large proportion 
of cases measles runs so typical a course that the diagnosis is very easily 
made, yet such great variations in type are alwws liable to occur that 
we should be extremely careful not to make a diagnosis of certain other 
diseases, such as rubella, except under unusual circumstances. This is 
important, because we know that during epidemics of well-marked measles 
all these great variations as to incubation, prodrome, efflorescence, desqua- 
mation, and the entire course not infrequently arise. 

A case which occurred in my wards at the City Hospital during an 
epidemic of measles which took place in that institution illustrates how 
greatly the symptoms and appearance of the disease may vary. The cases 
occurring in the hospital were almost without exception of the typical form, 
in which no mistake could be made as to the diagnosis of measles. 

A girl (Case 253) who was in tlie hospital, and who was exposed to infection from 
the patients with measles, after feeling perfectly well on the previous day, was found in the 
morning to have slight coryza, cough, and a papular efflorescence not confluent even on 
the face, small in size, light pink in color, and not crescentic. "While the efflorescence 
lasted the appetite was somewhat lessened, and the temperature was about 37.5° C. (99.5° 
¥.). At the end of twenty-four hours the efflorescence had almost faded, and in a few days 
the general symptoms passed away, the patient's appetite had returned, the temperature 
had become normal, and she seemed perfectly well. 

If this case had been met with as a sporadic one it would have been impossible to 
make the diagnosis of measles, and from its mild nature it would have been supposed to 
be some slight form of disease, such as rubella, 

I have met with cases of this type quite frequently, both during epi- 
demics and sporadically ; their cause is always obscure, and in them the 
diagnosis between measles, rubella, and papular erythema is often impossible. 

In this next bed is a little girl (Case 254) who is convalescing from measles and is 
slightly desquamating. The record states that she was attacked with cough, coryza, 
lachrymation, a temperature of 39.4° C. (103° F.), a pulse of 120, and respirations slightly 
quickened. On the second day of the attack these symptoms abated somewhat, and the 
temperature fell to 38.3° C. (101° F.). On the following day the temperature 'rose to 
39.7° C. (103.5° F.) in the morning, and in the evening to 40.5° C. (105° F.). At this 



584 



PEDIATRICS. 



time an efflorescence, papular in character, appeared on the face, and by the fourth day had 
spread rapidly to the body and limbs On this day the temperature fell to 38.8° C. (102° 
F.) towards the middle of the day, and by evening to 38.6° C. (101.5° F.). On the morn- 
ing of the fifth day the temperature was 37° C. (98.5° F.) in the morning and 37.5° C. 
(99.5° F.) in the evening. The temperature was then normal for two days, but on the 
eighth day the child was found to have a temperature of 37.7° C. (100° F.), and to be com- 
plaining of pain in the left ear. A marked congestion of both membranse tympani with a 
slight serous effusion was all that was detected. The temperature, after fluctuating from 
86.6° to 37.7° C. (98° to 100° F.) for two or three days, fell to the normal, and the conges- 
tion of the ears subsided. During the time when the ears were affected the eyes were 
very sensitive to light, and there was considerable conjunctivitis, of which the child com- 
plained greatly. The cough was also very troublesome, and was evidently caused by an 
irritation of the mucous membrane of the throat, as at no time was any bronchial irritation 
detected. 

It is to be noticed in this case that the congestion of the membranae tympani occurred, 
as I have already described, during a period closely following the efflorescence on the face. 

Here is the chart (Chart 18) which represents the temperature during the stage of 
invasion and efflorescence in this case, and also the accompanying mild congestion of the 
membranae tympani which is so common in measles. 

CHAKT 18. 





J)&i/s of Disease 


n 


F 


1 


2 


3 


4 


5 


6 


7 


8 


9 


10 


II 


12 


13 


14 


c 


107° 
106° 
105° 
104° 
103° 
102° 
101° 
100° 
99° 

MORML 
TEMP 

98° 
97° 
96° 
95° 


M E 


M E 


" 


M E 


M E 


M E 


M E 


M E 


M E 


Si e 


M E 


M E 


M E 


M E 


416° 

41.1° 

40.5° 

40.0° 

39.4° 

38.8° 

38.3° 

37.7° 

37.2° 
37.0° 
36 6° 

36.1° 

35.5° 

35.0° 
































3 


m 


'or 


HSl 


'6>/ 


ce 




















/ 


\ 


























( 


\ 




























\ 
























/^ 




^ 








Co 


7(/t 


?sl 


(of 


} 




















y 


Oi 


-e 


2A2 
















/ 






f 


V 


y 


1 














1/ 






— 


- — 




1^ 


^~" 



















































































































Measles with congestion of membranfe tympani during stage of efflorescence. 



Complications and Sequels. — There are quite a number of compli- 
cations and sequelae which may occur in the course of measles. The most 
common of the serious ones are pertussis, pneumonia, and tuberculosis. 

The first-named disease seems to have an intimate connection with measles, 
and its occurrence in the course of measles renders the prognosis more grave. 

The bronchitis which is so common an accompaniment of measles some- 
times appears in a more severe form, attacking the smaller bronchi as well 
as those of medium size, and may result in a broncho-pneumonia, which 
is much more common as a complication of measles than is lobar pneumonia. 



THE EXANTHEMATA. 585 

The broncho-pneumonia does not, however, appear to be more severe when 
it arises as a complication of measles than when it occurs separately from 
that disease. Broncho-pneumonia as a complication of measles may occur 
very early in the course of the disease, even during the stage of invasion ; 
but it occurs most commonly towards the end of the second week. 

When, therefore, after the efflorescence has faded and the fever has 
subsided, the temperature again rises without evidence of local irritation in 
the throat, ear, or glands, we should suspect that a broncho-pneumonia is 
developing. 

The additional symptoms of quickened respiration and the movement 
of the alse nasi will render still more probable the supposition that this com- 
plication is arising, even though nothing abnormal is detected in the lung 
itself. This absence of abnormal physical signs in the lung in the early 
stage of broncho-pneumonia is quite common, and I shall defer a fiu*ther 
description of them, as well as of the disease itself, until a later lecture 
(Lecture XLIX., page 962). In infants the temperature of tuberculous 
broncho-pneumonia does not seem to differ very much from that of ordinary 
non- tuberculous broncho-pneumonia. 

The congestion of the larger bronchi, which appears to be almost a 
part of measles, may become subacute and chronic, instead of, as is usually 
the case, passing off soon after the maximum of the temperature and efflo- 
rescence. 

Pleurisy may occur in the course of measles, but is not so common as 
pneumonia. 

Among the rarer complications of measles are empyema, endocarditis, 
pericarditis, and membranous laryngitis. 

Catarrhal laryngitis and tracheitis are not infrequent accompaniments 
of the acute stage of measles. CEdema of the glottis is rare, but has been 
known to occur. 

When an otitis occurs as a complication of measles it is characterized by 
the symptoms which I have already described (page 575). In treating this 
complication the nose and naso-pharynx should be kept as clear as possible. 
The ear should be, as in the cases which I have already described in speak- 
ing of the treatment of the ear in scarlet fever, gently inflated by means of 
the Politzer bag, and the atropine solution (Prescription 70, page 559), to- 
gether with dry warmth, should be used. 

A case w^hich came under my observation illustrates so well this aural 
complication occurring in measles that I shall report it to you. 

A girl (Case 255), one year and seven months old, previously well, was attacked on 
March 6 with coryza, cough, lachrymation, a heightened temperature, quickened respira- 
tions, and a quick pulse. An efflorescence of measles appeared on the face on the following 
day, and the child felt sick, coughed continuously, and had a hoarse voice. The respira- 
tions varied from 36 to 40, the pulse from 170 to 180. The skin was hot and dry, and 
the throat was somewhat reddened. In the afternoon the temperature in the axilla was 
found to have risen to 40.2° C. (104.8° F.). She vomited and had a convulsion. The 
nervous symptoms passed off in a few hours, free pei-spiration followed, and the cough 



586 PEDIATRICS. 

became somewhat looser. At 8 o'clock in the evening the temperature was 40.1° C. 
(104.4° r.), the respirations were quickened, and the pulse was rapid. Nothing abnormal 
was found on physical examination of the chest. During the night she was somewhat 
delirious, and very wakeful and fretful. The temperature remained at about 40° C. (104° 
F.), the respirations were rapid, and the alee nasi moved so perceptibly that it seemed 
as though a pneumonia must be developing. Frequent and careful examinations of the 
lungs, however, failed to show anything abnormal. She continued to be very restless 
during the night, and the efflorescence appeared thickly on the abdomen and legs, but 
very slightly on the chest. She complained of pain in the chest from the continuous 
cough, but did not show any symptoms of pain or discomfort elsewhere. Towards morn- 
ing it was found that an otitis of the left ear had developed, which in a few hours 
caused perforation of the membrana tympani. As soon as there was a free flow of pus 
from the ear the temperature fell to 38.3° C. (101° F.), the respirations became quiet and 
normal, the alse nasi ceased to move, and the child fell into a quiet sleep. On the next 
day the efflorescence was pronounced all over the body, face, and extremities. From this 
time the measles ran its usual course, and was followed by desquamation and complete 
recovery. 

The aural complication, however, proved to be very intractable, and, although it was 
carefully treated by Professor Blake, lasted for many months. The perforation of the 
membrana tympani did not completely heal for over a year, but the case finally resulted 
in complete recovery without any disturbance of hearing. 

In addition to the conjunctivitis which is a common accompaniment of 
measles, and which, as a rule, requires no treatment beyond the protection 
of the eyes from light, the inflammatory process may extend to the deeper 
tissues of the eye and cause other grave lesions, such as blennorrhagic 
conjunctivitis, keratitis, and iritis. These complications should be treated 
at once by a skilled oculist. 

Tobeitz has called attention to the deleterious influence of measles in 
rendering more active any subacute or chronic aflections of the eye which 
may have existed previous to the disease. 

In a number of cases an acute swelling of the thyroid gland may take 
place during the course of measles. This swelling of the thyroid gland may 
even cause marked dyspnoea by pressure, but it usually disappears in two or 
three days. In some cases, however, a formation of pus has taken place, 
followed by destruction of a part of the gland. In intractable cases of this 
kind it has been found that the external application of iodine is useful. 

Enlarged cervical glands are not so common in measles as in scarlet 
fever, but they may occur, and may even prove serious from the occurrence 
of suppuration. 

At times, at the height of the efflorescence, albumin may appear in the 
urine ; but this is frequently merely a transient congestion of the kidney, 
due to the high temperature, and corresponding to the same condition in the 
period of efi&orescence in scarlet fever. Nephritis may complicate measles, 
as it does scarlet fever, but it is comparatively rare. 

The irritation of the intestine, which I have already referred to as 
occurring commonly during the height of the efflorescence and temperature, 
sometimes becomes much more severe from the development of colitis as a 
complication. 



THE EXANTHEMATA. 587 

The most common sequela of measles is tuberculosis. This mav occur 
either as a general miliary tuberculosis or as tuberculous disease of anv 
of the organs or the joints. Tuberculous disease of the joints seems to 
show a special predisposition to follow attacks of measles. It is noticeable 
that where a patient with a tuberculous joint has an attack of measles 
the process in the joint is apt to become temporarily more active, and the 
prognosis is consequently more grave. The organ which in measles is 
most commonly affected by tuberculosis is the Imig, and the most common 
form of tuberculosis of the lung is a tuberculous broncho-pneumonia. You 
must remember, however, that a tuberculosis of the limg may often occur as 
a sequela of measles where pneumonia has not been present. In infants the 
temperature of tuberculosis, as has been observed by Holt, does not seem 
to differ very much from that of an ordinary broncho-pneumonia. In 
regard to the relation which exists between measles and tuberculosis, we 
should appreciate the danger, which seems to be a serious one, that the micro- 
organism of measles will render active an old and quiescent tubercular 
nidus, w^hether it be in the bronchial or the cer\^cal glands or elsewhere. 

I have here a case to show you which represents the infection of a patient 
with measles by the bacillus tuberculosis. 

This girl (Case 256)j six years old, was always well until about one year ago, when she 
had an attack of measles. Although there was no acute pulmonary affection following the 
attack of measles, she began to be affected with slight dyspnoea and a cough about one 
month after the measles had ended. Since then these symptoms have increased, and she 
has lately had swelling of the feet and has complained of a general malaise. She has 
also lost considerably in weight and strength. On physical examination dulness is found 
at the apices of both lungs, and over the dull areas coarse and fine moist rales. Nothing 
abnormal is found in connection with the heart or kidneys. The temperature varies from 
37.7° to 38.8° C. (100° to 102° F.), the respirations from 30 to 50, and the pulse from 120 
to 130. An examination of the sputum shows the bacillus-tubercle to be present. This is 
evidently a case of pulmonary tuberculosis following an attack of measles. 

Another sequela, though a rare one, is paralysis. Cases thus complicated 
have shown mostly a paraplegia, and, according to Osier, frequently can be 
classified as post-febrile polyneuritis, although it is possible that some of 
them may be due to a rapidly ascending myelitis. 

A very rare sequela of measles is the disease noma (cancrum oris). I 
have here in one of the isolating rooms a case which illustrates the sec^ueuce 
to measles of broncho-pneumonia and noma. 

This child, a girl (Case 257), four years old, had a severe attack of whooping-cough. 
When the whooping-cough had lasted six weeks, she was attacked with measles. Towai-ds 
the end of the second week of the measles the child was attacked with a broncho-pneumonia. 
This pneumonia was not of an unusually severe type, but it lasted for five or six weeks and 
left the child in a very weakened and debilitated condition. During the pneumonia the child 
was not well cared for, and this complication arose, for which she has entered the hospital. 

As I shall refer to this case later (page 793), when speaking of diseases of the mouth, 
I shall show it to you now merely as a case of noma which I am having actively treated, 
but in which the prognosis is very unfavorable. "When noma occurs as a complication of 
measles and pneumonia it is generally fatal. 



588 PEDIATRICS. 

RUBELLA (Rotheln). — It is now almost universally believed that there 
is, in addition to variola, varicella, scarlet fever, and measles, a highly 
infectious acute disease accompanied by an efflorescence on the skin which 
is distinct from these other members of the group of exanthemata. While 
we must recognize the propriety of mentioning the existence of this disease 
when speaking of this class of affections, we must also acknowledge that it 
is the weight of opinion, and not of proof, which has characterized rubella 
as a disease sui generis. The cause, the symptomatology, and the resulting 
diagnosis and treatment of rubella must be left for future investigation, 
until the special micro-organism which produces it and that which produces 
measles can be separated bacteriologically. The difficulty which arises in 
differentiating rubella from the other diseases of this class is chiefly in dis- 
tinguishing it from measles. We cannot describe a typical case of rubella 
in such a way as to enable us to diagnosticate the disease in a sporadic case. 
On the other hand, this can be done so readily with the other exanthemata 
that we can at once diagnosticate a sporadic case of these diseases. Rubella 
is described in many ways by observers in different localities, but is usually 
spoken of as essentially a highly infectious disease, with an incubation of 
two or three weeks, with slight or no prodromata, and with a slightly raised 
temperature, accompanied by mild catarrhal symptoms, and often by sore 
throat and swelling of the cervical and post-auricular glands. 

The efflorescence is commonly described as papular or macular in form, 
of light grade, often evanescent, and seldom showing any desquamation. 
Complications or sequelae following rubella are said to be uncommon. If 
you will bear in mind what I have told you concerning the variations which 
occur commonly during epidemics of undoubted measles, you will see at 
once that this description of rubella is one which may be applied to many 
mild cases of measles. As, however, epidemics arise in which these charac- 
teristically mild symptoms occur in many cases, and as these give rise to 
like cases, it is probable that in the future a micro-organism distinctive of 
rubella may be found. 

Bearing these facts in mind, we can merely say, regarding rubella, that 
its diagnosis cannot be made in a sporadic case, that the prognosis is good, 
and that the treatment is the same as that of a mild case of measles. 

It may perhaps aid you to carry in your minds more clearly the charac- 
teristics of the group of exanthemata, which I have endeavored to explain 
to you, if in a few words I speak of this group of diseases as a whole. 

In none of these diseases has the specific organism been determined. 
When it shall have been, its detection will enable us to state definitely 
which disease we have to deal with, whether measles or scarlet fever, and 
even in the atypical cases of measles we can decide whether we have a 
case of true measles or of some disease such as rubella, which closely 
simulates its irregular forms. 

By referring to this table (Table 97) you can at a glance ascertain the 
chief points of differential diagnosis in the exanthemata. The figures and 



THE EXANTHEMATA. 



589 



the statements are merely approximate, but in this way the diagnosis of 
these diseases is much simplified and their characteristics are made more 
prominent. 



TABLE 





Variola. 


Varicella. 


Scarlet Fever. 


Measles. 


Rubella. 


Incubation , . 


12 days. 


17 days. 


4 days. 


10 days. 


21 days. 


Prodromata . . 


3 days. 


A few hours. 


2 days. 


3 days. 


A few hours. 


Efflorescence . 


Macules. 
Papules. 
Vesicles. 
Pustules. 


Vesicles. 


Erythema. 


Papules. 


Papules. 


Desquamation . 


Large crusts. 


'Small crusts. 


Lamellar. 


Eurfuraceous. 








Complications 
and sequelae. 


Larynx. 
Lungs. 




Kidney. 

Ear. 

Heart. 


Eye. 

Lung. 
Tuberculosis. 






Although what I have shown you in this table is far from definite, and 
might, were one of the diseases to be diagnosticated, be very misleading, yet 
for diiferential diagnosis between all these diseases I think you will find it 
valuable because of its simplicity. 

In addition to the leading points which I have indicated in the table, 
the general symptoms and the temperature of these diseases provide us with 
excellent material by which to distinguish one from the other. 

The slow progressive development of variola is very distinct from the 
acute, rapid course of all the others. The vomiting and sore throat of 
scarlet fever are usually quite distinct from the coryza, lachrymation, and 
cough of measles. In variola the rise of temperature during the prodromal 
stage, its decided lessening at the time of the appearance of the efflores- 
cence, and its gradual rise again during the stage of suppuration, are 
very distinct from the sudden rise of temperature in scarlet fever during 
the prodromal stage and up to the height of the efflorescence. In like 
manner the temperature in measles differs from that of the other diseases 
in its sudden rise on the first day of the prodromal stage, in its lessening 
on the second day, and in its rise on the third day and up to the height 
of the efflorescence. The manner of the decline of the temperature differs 
in variola, in scarlet fever, and in measles. While in variola it is slow 
and prolonged, in scarlet fever it is rather rapid, although it declines by 
lysis, and in measles the fall is often by crisis. In contradistinction to 
variola, scarlet fever, and measles, varicella and rubella differ markedly 
in the absence of a prodromal stage, in their short duration, and in their 
evanescent and moderate temperature. 



DIVISION XI. 

DISEASES OF THE NERVOUS SYSTEM, AND THE 
MYOPATHIES. 



IvEcxxjre: XXVII. 

INTRODUCTION. 

To-day, gentlemen, we shall begin to study a class of diseases which is 
the most difficult to understand of any that are met with in early life. This 
difficulty exists necessarily from the complex organism of the parts affected, 
and on account of the important rdle which the nervous system plays in all 
diseases which occur in human beings during the process of their develop- 
ment. We are much more likely to meet with nervous phenomena of the 
most diverse varieties in children than in adults. In like manner we meet 
with the most widely differing clinical symptoms. If you had studied the 
clinical symptoms of nervous diseases in the adult only, you would be in- 
sufficiently prepared to diagnosticate properly from similar symptoms in the 
case of the child. Symptoms which if occurring in adults would be sig- 
nificant of serious lesions of the nervous system may arise in children from 
simple reflex conditions which only simulate and do not represent actual 
disease. 

Children are much more apt to become unconscious, to have convulsive 
attacks, and to show disturbance of the functions of important nervous 
centres from reflex irritation, than are adults. The whole cerebro-spinal 
system in infancy and early childhood is so impressionable, so excitable, 
and so hypersensitive to even slight grades of irritation, that diseases of a 
nervous type, whether primary or secondary, dominate all others. 

We have, then, not only well-recognized pathological lesions with their 
characteristic symptoms, as in adults, but also the same groups of symp- 
toms caused by different pathological conditions, and, again, reflex nervous 
phenomena without organic lesions, ad infinitmn. 

These reflex phenomena are so much more numerous than those which 
arise from organic lesions, and are so irregular in their manifestations, that, 
from a diagnostic point of view, they are most important. They also enter 
590 



DISEASES OF THE NERVOUS SYSTEM. 591 

into all disturbances of the nervous system, whether functional or organic, 
to such a degree that what we have learned concerning cerebral localization 
in the adult becomes of much less value in the young subject. Attempts 
to locate minutely diseases of the nervous system by means of cerebral 
localization are so indefinite, and in the hands of the general practitioner 
so fruitful of incorrect conclusions, that I have thought it better to pay 
very little attention to this branch of neurology, which for the present 
should be referred to the nervous specialist. 

Difficult as the study and clinical recognition of these manifold condi- 
tions are, far greater becomes our task when we attempt to classify and 
arrange in simple form for the purpose of teaching the complex nervous 
phenomena which we meet with in our nursery practice. Diseases of the 
nervous system constitute in themselves the study of a lifetime, and we 
who are busily engaged in general medicine cannot hope to obtain the exact 
detailed knowledge of the nervous specialist. The nervous specialist, on 
the contrary, who has not worked practically among children, studying 
them in all their various phases of excitement and rest, disease and health, 
may fail to grasp the special phase of nervous disease by which he is at 
times confronted. 

The various pictures of nervous diseases which I shall present to you 
are those which you will be most likely to meet with in practice. As it is 
macroscopic rather than microscopic knowledge which is most needed for 
clinical observations in childhood, I shall treat the subject broadly, leaving 
the finer touches for your later and more extended study of the works of 
skilled neurologists. 

We must adopt some division for teaching which by its simplicity will 
aid us to keep m mind the various diseases in a connected series. As the 
mind grasps more readily symptoms produced by a distinct pathological 
lesion than those where such a lesion has not been proved to exist, I shall 
speak first of the principal organic lesions of the brain and cord, reserving 
for later lectures what I have to say about the various nervous phenomena 
which from our indefinite knowledge concerning them we term functional. 
I have adopted this division simply for the purpose of clearness in teaching. 
It is not that of any especial authority on nervous diseases, but it is what 
I have found to satisfy practically the needs of the many classes of students 
whom I have met from year to year. 

The terms ansemia and hypersemia of the vessels of the brain, as desig- 
nating distinct diseases, have been used frequently in connection with the 
discussion of diseases of the brain and cord. These terms should in the 
present state of our knowledge be restricted to represent symptoms, and 
not diseases, for in the majority of cases they are only symptoms which are 
secondary to some primary disease. 

Nervous diseases can as a whole be divided, as may be seen in this 
table (Table 98, page 592), into — I. Organic; II. Presumably Organic; 
III. Functional. 



592 



PEDIATRICS. 



TABLE 98. 

I. Organic "Where there is a distinctly definite pathological condition. 

Examples Meningitis. Hydrocephalus. 

II. Presumably Organic . Where there is no definite lesion, so far as we can at 

present determine, but where we suppose that a patho- 
logical condition may in the future be discovered, and 
that the disease may then be relegated to the organic 
class. 

Examples Chorea. Epilepsy. 



III. Functional. 

1. Probably Central 

Examples 

2. Reflex 



Examples 



Where apparently the symptoms arise from a disturbance 

rather than a lesion of the nervous centres. 
Hysteria. Tem.porary aphasia from, fright. 

Where the symptoms are caused by peripheral irritation 

of various parts of the nervous system. 
Convulsions from foreign bodies in the st6m,ach. Asthma 



Under each of these divisions I have tabulated the various diseases 
which belong to it, and I shall speak in detail only of those which you 
will be likely to meet with in general practice. 

By referring to this second table (Table 99) you will see at a glance 
which diseases I am about to describe to you, and the order which I have 
followed in describing them. 

I would also call attention to the fact that this table is not arranged on 
either a purely pathological or a purely symptomatic basis. On the con- 
trary, wherever it seemed expedient to designate a disease by the name of 
its principal symptom I have done so, although in most cases I have used 
a pathological term. The table, then, does not represent a recognized scien- 
tific classification of nervous diseases, but is merely a list of the different 
diseases in the order in which I shall speak of them. 





TABLE 99. 






Nervous Diseases. 

1 




1 1 1 

I. Organic. II. Presumably Organic. III. Functional. 




Probably Central. 


Reflex. 


Non-tubercular men- Chorea. 


Hysteria. 


Pavor nocturnus 


ingitis. Epilepsy. 


Hypnotism. 


(peripheral). 


Tubercular menin- Insanity. 


Catalepsy. 


Dental reflex. 


gitis. 


Simulated diseases. 


Keflex nystagmus. 


Thrombosis of the 


Insolation. 


Keflex of ear. 


cerebral sinuses. 


Concussion. 


Keflex of larynx. 


Hydrocephalus. 


Temporary amnesia. 


Paroxysmal gasping. 


Cerebral abscess. 


Temporary aphasia. 


Keflex of lung. 


Cerebral paralysis. 


Arrested psychical 


Keflex cough. 


Athetosis. 


development. 


Keflex of heart. 



DISEASES OF THE NERVOUS SYSTEM. 



593 



TABLE 99.— Continued. 
Nervous Diseases. 



I. Organic. II. Presumably Organic. III. Functional. 

Probably Central. Reflex. 

Intra-cranial tumors. Eetarded speech. Eeflex of stomach. 

Intra-cranial syphilis. Headaches. Reflex of bladder. 

Idiocy. Vertigo. Eeflex of vagina. 

Mirror- writing. Sensitive spine. Eeflex of rectum. 

Myelitis. Tetany. 

Poliomyelitis anterior. Pavor nocturnus 

Paralysis from caries (central), 

of the spine. 

Hereditary ataxia. 

Locomotor ataxia. 

Syringomyelia. 

Multiple cerebro-spi- 
nal sclerosis. 

Cerebro-spinal menin- 
gitis. 

Ifeuritis. 

Multiple neuritis. 

Paralysis of the new- 
born. ^ 

^Neuralgia. 

I must impress upon you the fact that the classification which we may 
deem best to adopt to-day will in all probability in the next five or ten years 
have to be modified by the further study of nervous pathology. You will 
notice, however, that in my classification I have allowed for this progress in 
medical thought, and that the various diseases which I have tabulated in the 
divisions ^^ Presumably Organic" and ^' Functional" can be placed in the 
class of " Organic Diseases" as soon as it has been proved that they belong 
there. 

In studying the various diseases of the nervous system which I shall 
explain to you, and the cases which illustrate them, I have received so 
much aid from the special knowledge of these diseases possessed by Dr. 
William N. Bullard that I wish to acknowledge my indebtedness to him. 



594 



PEDI^.TKICS. 



IvECTTURK XXVIII. 

I. ORGANIC NERVOUS DISEASES. 



Beain. — Cord. — Brain and Cord. — Peripheral Nerves. 

BRAIN. — Before speaking of the diseases of the brain I should like to 
have you examine a section of the skull as shown in this diagram (Diagram 
8). It represents the relations between the bone, the dura mater, the sub- 
dural space, the arachnoid, the subarachnoid space, the pia mater, and the 
brain. The diagram is useful for the clinical investigation of nervous 
diseases, and will, I think, aid you in miderstanding what I am about to 

describe. 

Diagram 8. 



Bo. 

D. M. 

— . Sub. D. S. 

A. P. or A. 
f" P. S. or Sub. A. S. 

^^^~^V. P. orP. M. 
"""-Br. 




Section of skull and brain. 

Bo Bone. 

!>• ^ Dura mater. 

Sub. D. S Subdural space. 

A. P. or A Arachno-pia or arachnoid. 

P. S. or Sub. A. S Pial space or subarachnoid space. 

V. P. or P. M Visceral pia or pia mater. 

Br Brain. 

W. M ^Miite matter. 

B Brain. 

Gr- M Gray matter. 

The dura mater is closely attached to the skull at all ages, but especially 
so in childhood. 

The subdural space lies between the dura mater and the arachnoid. 

The subarachnoid space is crossed by fibres, thus making a connection 
between the arachnoid and the pia, which some anatomists are now inclined 
to speak of as one structure. 



ORGANIC NERVOUS DISEASES. 595 

Meningitis. — If you will again glance at this table of classification 
(Table 99, page 592), and at the anatomical diagram (Diagram 8, page 594), 
you will see that I should naturally first speak of diseases of the cerebral 
meninges. Of these diseases meningitis ls the most common. Cerebral 
meningitis may affect the dura mater or the pia mater. In the first case it 
is called pachyineningitis, and in the second leptomeningitis. The form may 
be acute or chronic. 

Pachymeningitis. — Pachymeningitis is in early life so rare, except 
from certain local traumatisms, or as a lesion in some specific disease, such 
as syphilis, that we need merely mention it, and can at once proceed to 
study the inflammatory conditions of the pia mater. 

Leptomeningitis. — Leptomeningitis, on the contrary, is very frequent 
in childhood. It may be divided primarily as to its locality into (1) menin- 
gitis of the convexities, and (2) meningitis of the base ; as to its pathology, 
into (1) a simple non-tubercular inflammation of the pia, and (2) a groT\i:h 
of miliary tubercle in the meshes of the pia producing inflammation. 

This is only a general division, but it serves to prepare you for the 
somewhat more minute description which is necessary to make you imder- 
stand the varied clinical symptoms which are met with in these diseases, as 
the lines cannot be drawn sharply as to locality, pathology, or symptoms. 

(1) Xon-Tubercuear Meningitis. — Xon-tubercular meningitis is 
often called purulent meningitis, but the latter term does not seem so appli- 
cable as the former, because we also meet with a purulent exudation in certain 
cases of tubercular meningitis. The pathological process may, although in 
a general way and to the greatest extent affecting the membranes of the con- 
vexity, attack the membranes of the central and basic regions of the brain. 
Following, however, the rule that where we are making a clinical division 
of diseases we should emphasize the salient lesions by which we can in most 
cases distinguish them, I shall leave the minute pathology of these diseases 
for your more extended pathological studies. 

Non-tubercular meningitis in its acute form is a disease which may 
attack robust as well as debilitated children, and may occur at all ages. It 
is rare in the first year of life. It is most common in the middle period of 
childhood. 

Clinically, we sometimes find the non-tubercular form in infants simu- 
lating in its symptoms, on account of the locality affected, the tubercular 
form of the older child. On the other hand, the tubercular form in infiiuts 
is sometimes so acute in its symptoms as to simulate the non-tubercular 
form of the older child. 

Some rare cases of non-tubercular meningitis have been reported where 
the disease was apparently primary, and for the present, therefore, we can 
speak of this class of cases as idiopathic until further light has been thrown 
upon the subject. I myself have never seen a case of non-tubercular 
meningitis which was undoubtedly idiopathic. The great majority of cases 
is secondary. 



596 PEDIATRICS. 

Non-tubercular meningitis is most frequently of traumatic origin, as 
from some injury to the head, or the disease may arise from disease in 
the ear with its local inflammation extending through the petro-squamosal 
suture to the cerebral meninges. A comparatively small number of cases 
of non-tubercular meningitis appears to be caused by the specific microbe 
of such diseases as scarlet fever, measles, erysipelas, pneumonia, possibly 
typhoid fever, rheumatism, and syphilis. It also occurs in cerebro-spinal 
meningitis, and in rare cases it is secondary to a group of symptoms to 
which the name insolation has been given. 

This table (Table 100) designates the different causes which may give 
rise to non-tubercular meningitis. 

TABLE 100. 

Non-tubercular Meningitis. 

\ 



Primary (said to exist). Secondary. 



1 I I 

Traumatic. Ear. Specific diseases, sucla as 



Scarlet fever, 

Measles, 

Erysipelas, 

Pneumonia, 

Typhoid fever, 

Eheumatism, 

Syphilis, 

Cerebro-spinal meningitis. 

Insolation. 



Pathology. — The pathology of non-tubercular meningitis is practi- 
cally, where infants and young children are concerned, an inflammation 
of the pia mater. This, according to Delafield and Prudden, may be acute, 
chronic, tubercular, or syphilitic. 

In any case of acute meningitis the inflammation is apt to extend down- 
ward and to involve the pia mater of the cord. In young children it 
especially happens that the inflammation may involve the ependyma of the 
ventricles and cause a distention of these cavities with serum. 

In one form of acute non-tubercular meningitis the pia mater, according 
to Delafield and Prudden, from whose observations I shall freely quote, is 
somewhat congested. Its surface is dry, lustreless, and somewhat opaque. 
These changes in the gross appearances of the membrane are not marked, 
and may be overlooked, but the minute changes are more decided. 

There is an abundant production of cells somewhat resembling the cells 
which coat the surfaces of the membranes and fibres which make up the pia 
mater. The cell growth is general, involving the pia mater over most 
of the surface of the brain. The inflammation is one which results in the 
production not of fibrin, serum, or pus, but of new connective-tissue cells. 
This form of meningitis, which may be called axiute cellular meningitis, is of 



ORGANIC NERVOUS DISEASES. 597 

frequent occurrence, and is attended with the ordinary clinical symptoms of 
acute meningitis. 

Another form of acute non-tubercular meningitis has been termed the 
exudative^ because it is characterized by the accumulation, chiefly in the 
meshes of the pia mater and along the walls of the blood-vessels, of variable 
quantities of serum, fibrin, and pus. Sometimes one, sometimes another, of 
these exudations preponderates, giving rise to serous, fibrinous, or purulent 
forms of inflammation. The absolute quantity of the exudation varies 
greatly. In some cases death may be caused with so slight a formation of 
exudation that to the naked eye the pia mater may look quite normal or, 
perhaps, only moderately hypersemic or oedematous. The microscope, how- 
ever, in these cases will reveal pus-cells in small numbers, and sometimes 
flakes of fibrin in the meshes and along the walls of the vessels. In other 
cases turbid serum in the meshes of the membrane is all that can be seen, and 
the turbidity is shown to be due to pus-cells or to a small amount of fibrin. 
Again, either with or without marked oedema of the pia mater, yellowish 
stripes are seen along the sides of the veins, sometimes appearing like faint 
turbid streaks, and at other times dense, opaque, thick, and wide, so as 
almost to conceal the vessels. These are due to the accumulation of pus- 
cells and fibrin in large quantities along the vessels. They can be seen best 
and are most abundant around the larger veins which run along over the 
sulci. In still other cases the infiltration with pus and fibrin is so dense 
and thick and general that the brain- tissue, the convolutions, and most of 
the vessels of the pia mater are concealed by it. This is usually of a 
greenish-yellow color, and is sometimes so thick as to appear like a cast of 
the brain-surface at the seat of the lesion. Sometimes extravasated red 
blood-cells are mingled with the other exudations as the result of diapedesis. 
Microscopic examination shows numerous white blood-cells sticking in the 
walls of the veins and capillaries, or the vessels may be blocked with them. 
It is evident that a large part of the pus-cells accumulates as the result of 
emigration. The connective-tissue cells of the pia mater may be detached 
from their places or degenerated. In some cases there are considerable 
accumulations of pus between the pia mater and the brain-substance and 
along the vessels which enter the latter. More rarely, pus is found upon the 
free surface of the membrane. The brain-substance may be compressed by 
the accumulated exudation so that the convolutions are flattened. The cor- 
tical portion of the brain may be simply infiltrated wath serum (oedematous), 
or it may undergo degenerative changes and may be the seat of punctate 
hemorrhages. Not infrequently the inflammation extends to the ventricles, 
which may contain purulent serum, and to the pia mater of the cord. This 
form of infiltration is most frequent on the convexity of the brain, but may 
extend or even be confined to the base. It may be localized, but it fre- 
quently extends widely over the surfaces of the hemispheres. Bacteria are 
often present in the exudation, and I shall explain their relationship to the 
lesions when speaking of cerebro-spinal meningitis. 



598 PEDIATRICS. 

When recovery occurs from the acute exudative form of non-tubercular 
meningitis, there may be fatty degeneration of the cells which have accumu- 
lated in the pia mater, particularly along the vessels, and this may produce 
white patches in the membrane and threads along the blood-vessels, which 
resemble the accumulation of exudation in the acute stage. Fatty degener- 
ation of the blood-vessels and cells of the pia mater may also occur without 
acute inflammatory changes. Sometimes in children inflammatory changes 
in the ventricles persist for days and weeks after the subsidence of the in- 
flammation of the pia mater. 

The non-tubercular form of meningitis may also be chronic, in which 
case the pia mater at the base of the brain alone may be inflamed (basilar 
meningitis), or only the pia mater over the convexity, or the entire pia 
mater, or certain circumscribed patches of the membrane. In these cases the 
pia mater is thick and opaque, and there is a formation of new connective 
tissue, with a production of pus, fibrin, and serum. The relative quantity 
of these inflammatory products varies in different cases, and results in some 
cases in firm and at times extensive adhesions between the dura mater and 
the pia mater. Other conditions which represent the results of chronic 
inflammation may also be present, but need hardly be referred to here, 
further than to say that the ventricles of the brain may in this chronic form 
contain an increased amount of serum and may be dilated. The ependyma 
also may be thickened and roughened. 

Symptoms. — Where non-tubercular meningitis is secondary to injuries 
or to other diseases, the characteristic symptoms may of course be compli- 
cated and even obscured by symptoms resulting from the especial cause. In 
the supposed primary or idiopathic cases the symptoms, especially where the 
child is over two years of age, are rapid in their development. The course 
is short, from seven to eight days, and the disease may often prove fatal 
in forty-eight hours. The disease, when aflecting the convexities chiefly, 
begins with intense headache and a high temperature, 40°-40.6°-41.1° C. 
(104°-105°-106° F.). The respirations are rapid, 30-40-50, and compara- 
tively regular. The pulse is quick, 150-160-170, but is usually regular. 
Vomiting, photophobia, contracted pupils, and delirium are present. Con- 
vulsions occur early. Later we may have blindness and paralysis. 

Diagnosis. — As the diagnosis of non-tubercular meningitis is chiefly a 
differential one from tubercular meningitis, I shall reserve what remains to 
be said on this subject until I speak of the latter disease. 

Prognosis. — The prognosis is very unfavorable. It is possible, how- 
ever, for the child to recover completely from an attack of non-tubercular 
meningitis. Perhaps only a changed mental condition will remain, boys 
appearing effeminate or more easily excited than would be considered 
normal. Some of the more acute forms affect also the brain, and we find 
their results in idiocy and contractures. We must always bear in mind 
that children have wonderful recuperative powers. Their nervous organ- 
isms, although sensitive to the least shock or the slightest irritation, from 



OEGANIC NERVOUS DISEASES. 



599 



the activity of their growth present opportunities for repair which do not 
occur in adults. So long as a disease of a necessarily fatal character is 
not present, the possibility of recovery should not be lost sight of. Vio- 
lence of the nervous manifestations does not by any means always indicate 
a fatal issue. 

Treatment. — The treatment of non-tubercular meningitis varies with 
that of the disease or condition to which it is secondary. The child should 
be kept in a cool, dark room and protected from noise. In the treatment of 
meningitis, whether it is a symptom or whether it is idiopathic, the indica- 
tions are to reduce the temperature of the body and to support the general 
strength until the disease has run its course. The former is accomplished 
best by the application of mustard derivatives to the lower extremities, by 
sponging the entire body every three or four hours with water at a tempera- 
ture of from 15.55°-22.22° C. (60°-70° F.), and by the application of cold 
to the head. The strength should be supported by the administration of 
milk, and, when necessary, of stimulants. 

Case 258. 




Treatment of meningitis with Leiter's coil. 



The method of applying cold to the head by means of Leiter's coil is a 
valuable one, and I have here in this bed a child (Case 258) with meningitis 
who is being treated in this way. 

The apparatus called Leiter's coil is very simple, and consists of a light 
flexible metallic or preferably rubber tubing, which can be bent in any way 
desired and applied to any part of the body or limbs as well as to the head. 



600 PEDIATRICS. 

Two vessels are needed : one at a height somewhat above that of the child's 
head acts as a reservoir for the water, while the other stands under the bed 
to receive the water after it has passed through the tube. In this way we 
can have water at a constant temperature, warm or cold, continually running 
through the tube several times around the child's head. 

In addition to the local treatment, bromide of soda in varying doses, 
according to the age of the child and the severity of the disease, can be 
given. 

Dr. Praser reports the case (Case 259) of a male infant, fourteen months old, unusually 
well developed and previously perfectly well. It began to be irritable and to lose in weight. 
These symptoms continued for about a month. When it was brought to him it had a 
temperature of 37.4° C. (99.5° F.), and it had no other symptoms beyond what would be 
expected from the condition of the gums, which were hot and tender. Three days later a 
convulsion occurred, and two days later hemiplegia of the left side. The pulse was 130, 
small and irregular. The temperature was 38.6° C. (101.5° ¥.). Sensation was perfect on 
both sides. On the following night the infant began to have convulsions, which continued 
with irregular intervals until the next morning. The entire voluntary muscular system 
was then found to be in a state of tonic spasm. The legs were rigid, the head was retracted 
on the trunk, and there was opisthotonos. This tonic spasm was interrupted at intervals of 
half an hour by a clonic seizure involving chiefly the extremities. While these nervous 
manifestations continued, the thumbs and the fingers were bent into the palms, and the 
forearms were flexed and extended upon the arms with short rhythmical movements. 

The inferior extremities were similarly affected, though to a milder degree. The move- 
ments also extended to the face, giving rise to contortions. The respiration was irregular, 
but there was no lividity of the skin. The pulse was 140. The temperature was 38.8° C. 
(102° F.). Three days later, the previous symptoms having in the mean time continued, 
there was a diminution in the convulsions, but consciousness almost entirely disappeared, 
and there was an increasing tendency to coma. The pupils were contracted, there was an 
entire inability to swallow, and the infant gradually sank, dying at 6 p.m. 

The post-mortem examination was made twenty-four hours after death. On opening 
the skull and deflecting the dura mater the convolutions appeared flattened, as if they had 
been slightly compressed. The veins of the cerebral cortex were much engorged. The 
outer surface of the visceral layer of the arachnoid was smooth and dry, but at a spot about 
1.2 cm. (J inch) in diameter, situated about the middle of the ascending frontal and parietal 
convolutions of the left hemisphere, the pia mater was covered by a thin, yellowish layer of 
lymph. During the removal of the brain several ounces of clear serous fluid escaped from 
the lateral ventricles. On section of the hemispheres the centrum semi-ovale did not present 
any unusual number of vascular points on either side, but the substance of both hemi- 
spheres, especially that of the left, was very soft. 

The optic thalamus and lenticular nucleus of the left hemisphere were so much softened 
as to be almost difftuent. The ependyma of the lateral ventricles was soft and uneven, and it 
appeared in parts to be covered by a layer of lymph, but the surrounding tissues were so much 
softened that it was doubtful whether the layer consisted of lymph or of the smooth and 
softened ependyma. At the base of the brain a layer of lymph 0.3 cm. (^ inch) in thick- 
ness was found in the interpeduncular space underneath the visceral layer of the arachnoid. 
The inner surface of the dura mater at the base of the skull was smooth and without a trace 
of opacity. 

There was in this case a softening of the brain-substance, which was probably second- 
ary to the meningitis. 

This boy (Case 260), four years old, whom I have here to show you, is apparently suf- 
fering from the results of non-tubercular meningitis. He was always well and strong until 
the onset of the present attack, which occurred twelve weeks ago. He never has had any 
disease, with the exception of measles when he was three years old. 



ORGANIC NERVOUS DISEASES. 601 

This last attack, in all probability, was produced by a fall, in which he struck the back 
of his head. No cut or bruise was detected. Later, on the day of this fall, he began to com- 
plain of pain in his head and to vomit. He was very feverish, and lay in bed protecting 
his eyes from the light, as there was great photophobia. The bowels were regular, and he 
took small quantities of food. A week later he became delirious, and this condition con- 
tinued for two weeks. He was then brought to the Children's Hospital, and from time to 
time was delirious during a period of five weeks. The delirium was sometimes active, and 
then it would disappear and he would recognize his parents. He was very cross in the in- 
tervals of the delirium, and would roll his head from side to side. His appetite was poor. 
He never had any convulsions or paralysis. For a time, however, he had incontinence of 
urine. 

Since this attack he has been gradually growing better, and he is now comparatively 
well, although he sometimes complains of slight pain in his head, at which time the head 
feels hotter than at others. He also 'sometimes has a little photophobia, and when exposed 
to unusual heat or excitement is rather restless and fractious. His pupils have seemed to 
be slightly dilated, but their reaction is normal. 

The treatment has been simply to keep him perfectly quiet. His diet has been care- 
fully regulated, and 0.18 gramme (3 grains) of bromide of potash has been administered 
several times during the day. At present his pulse is 98 and regular, his temperature is 
36.2° C. (92.7° F.), and his respirations 25 and rhythmical. 

The diagnosis is probably traumatic non-tubercular meningitis. 

The next case (Case 261), which I have had brought to show you as possibly one of 
non-tubercular meningitis, is a child two and one-half years old. 

He was healthy at birth, and remained so until he was eleven months old, when he had 
an illness lasting for two or three weeks, characterized by high temperature, but no other 
definite symptoms beyond apparent irritation connected with the teeth. 

When he was seventeen months old he had a similar attack, only more severe, accom- 
panied by delirium, photophobia, high temperature, and, in a few days, paralysis of the 
legs and left arm, while he could only move the right arm slowly. He had a tendency 
to turn the head to the right, and his head was retracted. The ftecal movements and the 
urine were normal. He was unconscious for two days. An examination showed that there 
was nothing abnormal in the ears, nor was anything abnormal found on physical examina- 
tion elsewhere. He cried out as though he had severe pain in his head when the attack 
began. After a few days he began to improve rapidly, and, although he had never talked 
before, soon began to express himself in words. 

During the following year he had some trouble with his ears, and grew very weak, so 
that he could not walk. Later he had an attack of croup, accompanied by perforation of 
both membranse tympani. 

To-day, as you see, he is comparatively well. 

In regard to the diagnosis of these last two cases, we are only justified in saying that 
if they continue well, and do not show a return of cerebral symptoms, the most probable 
explanation of their condition is a non- tubercular meningitis. 

In this next bed is a little girl (Case 262), four years old, who fell and struck the back 
of her head. She did not complain of much pain until the next day, when in the evening 
her face was flushed, she vomited, was restless, and was constipated. On the next day the 
symptoms increased in severity, and two days later she entered the hospital. Her head was 
retracted. There was an erythematous condition of the skin of the face, elbows, and knees. 
The pupils were equal and reacted well. She was very restless, but showed no evidence 
of pain. Her pulse was 132, the respirations were 44, and the temperature was 39.1° C. 
(102.4° F.). She was able to take nourishment and to retain it. She had marked opisthot- 
onos. During the following night and day she moved her hands continuously, and early 
in the morning vomited. The erythema of the skin gradually faded away. She talked 
incoherently most of the time. The eyes were fixed. The feet and hands were cold. 

Yesterday at times she showed labored breathing and the pupils were dilated. The 
head was not retracted so much, but the muscles of the neck were very stiff". The pulse 
was much more feeble and slower. The abdomen was retracted, and there were petechiae 



602 PEDIATRICS. 

on the face, elbows, and knees, most marked on the right side. Last night she was very- 
restless and her breathing was again labored. 

To-day, as you see, there is considerable twitching of her arms and legs. The patellar 
reflexes are absent ; the plantar reflexes are diminished. Nothing abnormal is found on 
examination of the ears, throat, chest, and abdomen, or of the urine. 

This case is probably one of traumatic non-tubercular meningitis. The erythematous 
efflorescence and the petechiae would make me suspect that we might possibly be dealing 
with a case of cerebro-spinal meningitis. The symptoms, however, are not of so severe a 
grade as I should expect in the latter disease, while the acute onset following trauma would 
naturally point towards a simple inflammation of the pia mater. We cannot, however, in 
cases of this kind definitely determine the diagnosis without an autopsy. It is evident that 
there are no other diseases, such as typhoid fever or pneumonia, developing, and the possi- 
bility of its being a tubercular meningitis is exceedingly small, considering that she is at a 
period of childhood when the typical signs of this disease are most marked, and its type is 
of a subacute character. 

(Subsequent history.) On the following day she sank rapidly, and she died, without 
any spasmodic movements or convulsions, on the eighth day of the disease. 



ORGANIC NERVOUS DISEASES. 603 



LECTURE XXIX. 

BRAIN.— (Continued.) 
Tubercular Meningitis. 

The second form of leptomeningitis which I shall describe to you is 
called tubercular meningitis, and I happen to have a number of children 
illustrating this disease in the wards of the Children's Hospital to show you 
to-day. 

Tubercular meningitis is a disease caused by the tubercle-bacillus at- 
tacking the pia mater ; it occurs most commonly in early life, runs a sub- 
acute course, and is invariably fatal. The disease presents many irregu- 
larities in its manifestations, and its typical symptoms vary according to 
the age of the patient. The most typical cases of the disease are seen in 
middle childhood. It occurs more commonly between the ages of five and 
seven than at any other period of life. It is rare in the first year of life, 
especially in the early months ; the number of cases increases rapidly in the 
second year and decreases as rapidly after the eighth year. It is compara- 
tively so rare in adult life that out of the large number of adult patients 
that I have met in my service at the City Hospital only a few cases 
of tubercular meningitis have come under my care in the last ten years. 
Tubercular meningitis, then, can be considered to be essentially a disease of 
early life, and to be most common in the middle period of childhood. In 
a large number of cases there is a tubercular history of one or both parents. 
It is hereditary in the sense that the individual inherits tissues which are 
more or less receptive to and which provide a favorable material for the 
development of the bacillus of tubercle. 

Every child should be protected in all possible ways against tubercular 
infection, whether by its food or by human beings. The tubercle-bacillus 
appears at times to attack individuals in cases where the question of inheri- 
tance can absolutely be eliminated. We should, therefore, take the greatest 
care that children should not be under the care of tuberculous nurses, as 
the nurse is the member of the family who comes into the closest relation 
with the child. As an illustration of the truth of this statement I shall 
mention a case seen by me in consultation with Dr. W. L. Richardson and 
Dr. H. P. Jaques. 

A boy (Case 263), five years old, died of tubercular meningitis. The autopsy showed 
extensive tubercular lesions of the meninges, with enlarged bronchial lymph-glands and 
cheesy nodules at the apices of both lungs. The child up to the time of the attack had 
always been perfectly well. There was no history of tuberculosis on either the father's or 
the mother's side. There were several other children in the family, none of whom had ever 



604 PEDIATRICS. 

shown any symptoms connected with tuberculosis. This boy at the age of fourteen 
months was placed in the charge of a nurse about twenty years old, who remained with 
him until he was four and a half years old. Just before leaving the child she was 
brought into especially close connection with him while his parents were away for some 
weeks. The child was very fond of his nurse, insisted upon being in her lap a great deal, 
kissed her on the mouth, slept in her bed, and kept her in the nursery with him continu- 
ously. This nurse had a sister who died of pulmonary tuberculosis. She herself was 
taken sick with the same disease while taking care of the child, and subsequently died 
of it. 

Other cases of this kind have been known to occur. Of course the possibility of a 
coincidence must be thought of, but the fact that a robust child with no hereditary tuber- 
culous history lives in close connection with a tuberculous nurse and dies of tuberculosis 
of the bronchial glands and cerebral meninges is at least significant. 

It is not unusual to meet with a tubercular meningitis secondary to 
tubercular disease of the spine. This complication occurred in a child four 
years old whom I saw in consultation with Dr. Scudder. 

The child (Case 264) was being treated for Pott's disease with lateral deviation of the 
spine. He was placed on a frame for five weeks, and at the end of that time he lost in 
appetite and weight and began to have a cough. Nothing especial, however, was found in 
the lungs. The bowels became constipated, and he then began to have some mental dis- 
turbance and to vomit. A few days later he became unconscious, and on examining him 
his pupils were found widely dilated, uneven, and not responding to light. His tempera- 
ture was usually about 38.8° C. (102° F.). The pulse and respirations were somewhat 
quickened. His head was retracted, and on the day of his death he had a convulsion. 

Tubercular meningitis may also occur in connection with disease of the 
hip, the latter being much more common than when the spine is affected. 
I have seen a case of this kind in consultation with Dr. Brown which illus- 
trates the importance of recognizing the occurrence of this complication. 

A child (Case 265), four years old, was being treated by an irregular practitioner for 
disease of the hip-joint. The child had been allowed to drag itself about, and the treat- 
ment had been with drugs and not by apparatus. When the child was placed under Dr. 
Brown's care he had him taken to the country and placed in a house and room where all 
the hygienic surroundings were good. He kept the child in bed and treated it by means 
of the method of extension usually employed in these cases. The child at first began to 
improve, but after a few weeks lost in weight and in appetite. Its temperature, which had 
been varying from 37.2° to 37.7° C. (99° to 100° F.), rose to from 39.4° to 40° C. (103° to 
104° F.). A few days later the child became somnolent and had convulsions. 

When I saw the case with Dr. Brown it was evidently one of tubercular meningitis, 
apparently secondary to disease of the hip-joint, and the child died within twenty-four hours 
after I had examined it. 

In this connection I might mention that the tubercular form of otitis is 
not uncommon, and that it may be the starting-point for tubercular menin- 
gitis. Surgeons should, therefore, watch carefully the possible complication 
of tubercular meningitis when treating tuberculous disease of the bones and 
joints. 

A knowledge of the general pathology of tubercular meningitis is of 
great practical importance in acquiring a clear picture of the disease. 
We must look upon the tubercular lesions as secondary manifestations of a 



ORGAJSTC NERVOUS DISEASES. 605 

primary infection by the tubercle-bacillus of some other portion of the body, 
such as the bronchial or the mesenteric glands. Tubercular meningitis, 
therefore, is merely a part of a general tuberculosis. It, however, in early 
life is so prominent a part of tuberculosis, both in its clinical symptoms and 
in its pathological lesions, that I have placed it, not, as is usual in adults, 
under the heading of a general tuberculosis, but as a separate disease in my 
division of diseases of the nervous system. 

Pathology. — Although the nidus of the tubercle-bacillus which pro- 
duces the pathological lesions of tubercular meningitis is in some other part 
of the body, and the lesions of the brain and its meninges are always 
secondary, yet, as the clinical characteristics of the disease are those of a 
primary cerebral nature, I shall describe only the morbid lesions which 
occur in the brain. 

The macroscopic pathological condition which is seen in the brain as a 
result of the action of the tubercle-bacillus is a growth of miliary tubercle 
in the meninges and in the cerebral substance. This growth is especially 
marked in the meshes of the pia mater along the course of the blood-vessels 
at the base of the brain. These small granulations are conspicuously 
numerous in the choroid plexus and cause great irritation in the neighboring 
parts. This irritation is followed by a transudation of greater or less extent 
into the ventricles. Accompanying this transudation is also a fibrino-puru- 
lent exudation between the pia mater and the cerebral convolutions at the 
base of the brain, notably in the fissures of Sylvius, but at times covering 
the whole convexity of the brain. The amount of exudation is not pro- 
portionate to the number of tubercles. The ventricles are sometimes so 
distended as to burst the septum. Pressure is thus brought upon the 
central portions of the brain, involving especially the optic thalamus, the 
corpus striatum, and the corpus callosum. While, as I have stated, the 
symptoms vary in different individuals and at different ages, the patho- 
logical lesions, on the other hand, with the exception of their location, are 
comparatively stable. What is of especial interest to us clinically, however, 
is that, although in a typical case of tubercular meningitis in middle child- 
hood the symptoms, as a rule, correspond to the pathological lesions, yet 
in some cases we find an entire lack of such symptoms as would naturally 
result from the wide-spread and prominent lesions. 

Symptoms. — From what I have already told you in describing the 
symptoms of tubercular meningitis, we should first consider the course and 
the typical symptoms of the disease as it occurs in tlie middle period of 
childhood, and then state the variations which occur in infants. 

By carefully studying the pathology of tubercular meningitis we can 
almost deduce the sequence of symptoms which we should expect to meet 
with in the middle period of childhood. In fact, in the great majority of 
cases occurring between the ages of two and eight years this sequence is very 
striking. Kemember that as we are dealing with a symptom of general 
tuberculosis we should expect to find in the early stages of the disease that 



606 



PEDIATRICS. 



the nutrition is affected, that there are a lessened appetite, loss in weight, 
anaemia, and in fact symptoms which warn us that something is affecting 
the child's general health. This condition may last for many weeks, or 
even months, varying as to the time when the tubercle-bacillus has left its 
original nidus and migrated to the cerebral meninges. Only after this has 
occurred do we begin to get symptoms of cerebral irritation. The child 
now becomes peevish and capricious, and is in some cases easily frightened. 
As the tubercular growth increases and causes further congestion of the 
blood-vessels, the sleep is disturbed ; the child complains of dizziness and 
slight evanescent pains in the head ; it staggers slightly in its walk (static 
ataxia) ; sometimes it cries out sharply, especially at night (hydrocephalic 
cry). Vomiting not apparently connected with the food, and usually 
without nausea, is a common symptom. These are symptoms of irrita- 
tion of the nervous centres, and may last for a week or two, according to 
the development of the pathological lesions. The temperature is usually 
moderately raised, 37.2°-37.7°-38.3° C. (99°-100°-101° F.), but on some 
days it rises a degree or so higher, and just before death a considerable 
elevation may occur. This chart (Chart 19) shows the temperature of a 

CHAET 19. 





Days of Disease 




J^'. 


1 


2 


s 


4 


5 


6 


7 8 


9 


10 


11 


12 


13 


14 


15 


16 


17 


18 


19 


c. 


107° 
106° 
105° 
104° 
103° 
102° 
101° 
100° 
99° 

NORM'l 

TEMP. 

98° 

97° 

96° 
95° 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME, 


MEl 


urn 


MEl 


ME 


41.6° 

41.1° 
40.5° 

40.0° 

39.4 ° 

38.8° 

38.3° 

37.7° 

37.2° 
37.0° 
36.6° 

36.1° 

35.5° 
35.0° 






































1 






































/ 






































/ 








































s 






























/ 








H 
£ 


















/ 


1 










/ 


,/ 






S 
^ 




/ 


./ 


1 , 






/ 


l/ 


V 


U 


{/ 


^ 




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Tubercular meningitis. Male, 4 years old. 



child five years old who lately died in the hospital. It represents very well 
what you will usually meet with in uncomplicated cases of tubercular 
meningitis. Of course it is impossible to determine the exact day of the 
beginning of the disease in such an affection as tubercular meningitis, so 
that the first day marked on the chart is merely approximate and serves as 
a starting-point to show the character of the temperature. 

The pulse at first is somewhat quickened, but it soon becomes slower than 



ORGANIC NERVOUS DISEASES. 607 

normal, and is apt to intermit. The respirations may in the early part of 
the disease be quickened, and at times are of a sighing character. Obstinate 
constipation is a common symptom. Hypersesthesia of the skin, with occa- 
sional waves of congestion, especially of the cheeks, is sometimes met with. 
The pain in the head increases, and the child is apt to hold its hand to its 
head. Drowsiness, at first slight, soon becomes very marked. The child is 
apathetic and lies in bed, refusing to eat. The urine is scanty. There is 
photophobia, and the pupils are contracted. Tubercles in the fundus of 
the eye are rarely seen during life. Abdominal pains are quite frequent, 
and depression of the abdomen (boat-shaped) is noticed in a certain num- 
ber of cases. Drawing the finger over the skin usually produces a bright 
red line, which becomes in a few minutes quite intense, and lasts perhaps ten 
or fifteen minutes, which is much longer than would be the case in a healthy 
child. This phenomenon is called the tache cerehrale, and is quite frequently 
met with in tubercular meningitis, though it may be absent. This sign is, 
however, in no sense typical, and is seen in a number of other diseases. 
The child at this stage of the disease is apt to roll its head on the pillow 
almost continuously. 

The pathological irritation has now gone on to exudation, and we begin 
to get symptoms of pressure. If diarrhoea appears, we should suspect 
tubercle of the intestine. Sopor now comes on rapidly, and the child can 
be aroused only at times. Strabismus, nystagmus, and ptosis may appear. 
The pupils are dilated and irregular, and their reaction is lost. The Mei- 
bomian secretion is sometimes markedly increased. Convulsions, generally 
partial, and of a rather mild type, may appear. At times paralysis of the 
arm, or of the arm and leg (hemiplegia), and interference with sight (optic 
neuritis), may occur. In some cases the pulse now becomes markedly slow 
and irregular, 50-60-70, and it is very common to find an intermission in the 

CHAET 20. 




Pause 



Cheyne-Stokes respiration. Tubercular meningitis. Child, 4 years old. 

pulse, though this must not be considered as diagnostic of tubercular menin- 
gitis. The respirations may not be perceptibly diminished at first, but soon 
become slow, 10 to 15 in a minute. A peculiar form of respiration, called 
Cheyne-Stokes, usually occurs at this stage of the disease. This type of 
respiration is characterized by complete or almost complete cessation of the 
respiratory movements for a number of seconds. This is followed by a 
faint return of the respiratory movements, which gradually increase in 
depth, rising for five or six inspirations and then fading away again so as to 
be imperceptible. This chart (Chart 20) represents this type of respirations 



608 PEDIATRICS. 

occurring in the third week of the illness of a child four years old who died 
of tubercular meningitis. 

A heightened temperature in tubercular meningitis indicates a complica- 
tion of some kind, such as pulmonary tuberculosis, pneumonia, or tubercle 
in the intestine. At the end of the disease, however, the temperature rises 
rapidly, as do the pulse and respirations. Hearing, taste, and smell seem to 
be unimpaired for some time. The position which children with tubercular 
meningitis often take is somewhat characteristic. In all forms of meningitis 
they are apt to bury their heads in the bedclothes. There is often spasmodic 
retraction of the head, and they are inclined to lie with their knees drawn 
up. There may be spasmodic opisthotonos, as in this case which I shall 
presently show you (Case 272, page 618). The disease varies in its length, 
but usually lasts for from three to six weeks. Death may be preceded by 
continued convulsions for perhaps several hours. A striking feature which 
not infrequently occurs in the course of these general symptoms is a partial 
return to consciousness after the child has been lying in a stupor for several 
days. This phenomenon often induces the parents, and sometimes even the 
physician, to entertain hopes of improvement.- It is, however, always delu- 
sive, for it has no favorable significance, and is soon followed by a more 
profound state of unconsciousness. These symptoms which I have men- 
tioned do not, of course, always appear together, but may be present in 
different groups, varying with the individual. All the symptoms may dis- 
appear temporarily. There may be tonic as well as clonic contractions of 
the limbs and rigidity of the neck. 

Diagnosis. — The diagnosis of tubercular meningitis in the middle 
period of childhood, and with the sequence of symptoms which I have just 
enumerated, is not difficult, but you will at once perceive that the diagnosis 
in the early days or even in the first week of the disease must necessarily 
be very difficult. It is by watching the course of the symptoms and their 
general grouping, rather than by the consideration of any one symptom, 
or even one group of symptoms, that we are justified in making a definite 
diagnosis. The diagnosis, then, must, as a rule, be held in abeyance for 
many days. Reflex vomiting, with a moderate temperature, irregularity and 
intermission of the pulse, apathy, and many other symptoms of tubercular 
meningitis, I have often seen, both alone and in combination, in cases where 
they represented no cerebral lesion whatever. The active development and 
sensitive condition of the nervous system in childhood are so exaggerated in 
comparison with those of adults, that whatever disease may be present is 
liable to produce so profound an impression on the child's nervous centres 
that actual disease of these centres is readily simulated. Thus for days 
these apparently cerebral symptoms may mask by their undue prominence 
the symptoms of the real disease. 

Illustrative of this difficulty are certain cases (Cases 466, 467) of pneu- 
monia, which I shall describe to you in a later lecture (Lecture XLIX., 
page 984), in which the children had constant vomiting, soon became apa- 



OKGANIC NERVOUS DISEASES. 609 

thetic, and later were unconscious. They rolled their heads, had a medium 
temperature and an irregular pulse, and one of them showed irregularity of 
respiration. These symptoms lasted for five or six days, and disappeared 
with the development of an apex-pneumonia. 

Differential Diagnosis. — The differential diagnosis must be made 
between meningitis in general and other diseases, such as (1) diseases of the 
stomnch, (2) poliomyelitis anterior^ (3) pneumonia, (4) malaria, (5) typhoid 
fever, (6) syphilis, (7) rheumatism, (8) nephritis, (9) cerehro-spinal meningitis, 
and (10) non-tubercular meningitis. 

(1) Diseases of the Stomach. — Unless the child is very young, acute 
gastric symptoms are, as a rule, not difficult to recognize after the first few 
days. We may at times, however, be suspicious of cerebral disease on 
meeting in an infant with continual vomiting and an elevated temperature 
where there is no discoverable source of reflex irritation to account for the 
symptoms. This is especially the case if there are some irregularity of 
respiration and a slow pulse. These may be cases of tubercular menin- 
gitis such as I have described that disease in the first year of life. Again, 
however, they may be simply cases of reflex vomiting. As illustrative of 
this class of reflex gastric disturbance I shall cite this case : 

A male infant (Case 266), eight months old, was attacked with vomiting which lasted 
with short intervals for two days. There were apathy and slow, intermittent pulse. The 
temperature was 37.2° C. (99° ¥.). There were irregular respiration and rapid emaciation. 
This patient made a perfect recovery in four or five days, and the case was evidently of 
gastric origin. The slow, intermittent pulse, and the moderate temperature, which would 
have been so alarming in an older child, led me in this case, as in others in the first year 
of life, to eliminate tubercular meningitis. In my experience this interpretation of symp- 
toms has proved to be correct. 

(2) Poliomyelitis Anterior. — The following case of poliomyelitis an- 
terior resembled tubercular meningitis : it is, however, the only one which 
I have seen where the resemblance of the two diseases was so striking : 

A boy (Case 267), eighteen months old, showed for over a week symptoms closely simu- 
lating those of tubercular meningitis. Obstinate constipation and apathy were present, fol- 
lowed by unconsciousness ; there were also a marked tache cerebrale^ distended fontanelle, 
irregular pulse, contracted pupils, eyes turned upward, and convulsive attacks. Finally, 
paralysis of one of the arms appeared, the general symptoms passed ofl", and the diagnosis 
of poliomyelitis anterior was easily made. 

(3) Pneumonia. — The cases (Cases 466, 467) of pneumonia which I 
have referred to warn us that we should hold our diagnosis in abeyance, 
sometimes even for a week. 

(4) Malaria. — Although we must admit that malaria closely simulates 
almost any disease, it is not usual to mistake the malaria of older children 
for tubercular meningitis. In the first two years of life, however, malaria 
may affect so insidiously the general nutrition before its cliaracteristic symp- 
toms appear that some doubt as to the differential diagnosis may arise. 
The following case illustrates this fact : 

39 



610 PEDIATRICS. 

A male infant (Case 268), twenty months old, with a history of tuberculosis on the 
mother's side, began to show symptoms of anaemia and malnutrition with no perceptible 
cause, such as either improper food or bad general hygiene, to account for it. After two or 
three weeks it had attacks of unconsciousness lasting for hours ; at other times drowsiness^ 
with irregular pulse and respirations, was present. The temperature was 39.5° to 40° C. 
(103° to 104° F.). There were slight convulsions, and the fontanelles were distended. At 
first there was no periodicity of the symptoms, but a week later the attacks were evidently 
more pronounced every other day, and the infant was brighter on the intervening days. It 
lived in a malarial district. 

On the administration of quinine and on removing the infant to a non-malarial region^ 
these symptoms entirely disappeared. 

The detection of the plasmodium would, of course, have determined the diagnosis in 
this case, but it could not be obtained. 

Another case, which I saw in consultation with Dr. Parker, of Princeton^ 
is also very instructive in warning us how careful we should be in making a 
diagnosis of tubercular meningitis in cases where there is a possibility of 
malaria being the cause of the symptoms. 

A male infant (Case 269), fourteen months old, had always been well until fourteen 
days previous to the time when I first saw it. It then began to be fretful and to have 
diarrhoea. This condition continued for about a week, when it fell into a stupor, became 
very anaemic, and it was necessary to feed it by means of a dropper. At times it would cry 
out sharply. The temperature varied from 37.2° to 38.7° C. (99° to 102° F.). The respi- 
rations were usually regular, but at times were of the Cheyne-Stokes type. The pulse was 
about 120, sometimes regular, but at times intermitting. The pupils were sometimes con- 
tracted, but showed no irregularity. No other abnormal conditions were noticed, such 
as paralysis or symptoms connected with the lung, ear, heart, or throat, but the abdomen 
during the twenty-four hours previous to my examination was beginning to be depressed. 
The tache cerebrate was very distinct. 

On close inquiry I found that there was a slight periodicity in the symptoms, shown by 
a rise of temperature on each afternoon and followed by the stupor becoming somewhat 
less. Although the infant had been unconscious for a week, and was becoming weaker and 
taking less nourishment every day, yet, on the supposition that it might possibly be an 
obscure case of malaria, I decided that quinine should be administered in suppositories. On 
the next day a slight improvement was noticed in the infant in the afternoon. It appeared 
less comatose, but its temperature and pulse remained as on the previous days. On the 
following day, which was the second from the time that it had begun to receive the quinine, 
it rapidly became conscious and began to drink milk. On the following days it was reported 
to have had a restless night and to have had two slight convulsions. Its temperature in the 
morning was 38.2° C. (100.9° F.), and the pulse was 115 and not intermittent. On the 
following day there was marked improvement in every way, and this continued without 
interruption for the next four days. The infant then continued to improve rapidly, the 
temperature and pulse becoming normal, and some months later it was reported to be 
perfectly well. 

(5.) Typhoid Fever. — In my experience typhoid fever in young chil- 
dren is the disease which, next to non-tubercular meningitis, is most likely 
to simulate and be mistaken for tubercular meningitis. We may also have 
considerable difficulty in differentiating tubercular meningitis from the non- 
tubercular meningitis which may occur in the course of typhoid fever. The 
extreme cerebral congestion which at times arises as a symptom of typhoid 
fever may also add fresh difficulties to the differential diagnosis. The 



ORGANIC NERVOUS DISEASES. 611 

decisive point, however, between typhoid fever and meningitis, whether 
tubercular or non-tubercular, is the absence of leucocjtosis in typhoid 
fever and its presence in meningitis, provided that the latter is to any 
degree purulent. 

According to E. S. Wood, in meningitis the chlorides in the urine di- 
minish rapidly ; heating the urine precipitates the phosphates readily, and 
the amount of indoxyl is increased : the reverse of these reactions occurs in 
typhoid fever. 

(6.) Syphilis. — The history and general symptoms of syphilis are to be 
sought for where a syphilitic meningitis is suspected. The temperature is 
not especially high, and the symptoms are seldom acute. The pathology is 
said to be usually that of a chronic basic meningitis. 

(7.) Rheumatism. — Rheumatism is said to occur as a cause of menin- 
gitis, but this must be rare, and I shall merely mention it, as I have never 
met with a case of this kind. A high temperature and acute symptoms are 
said to be the rule in rheumatic meningitis. 

(8) Nephritis. — In addition to the other diseases which may simulate 
tubercular meningitis should be mentioned nephritis, in which the symp- 
toms of uraemia simulate, to a certain extent, those of tubercular men- 
ingitis. The urine should always be examined in doubtful cases of this 
kind, as where ursemic symptoms resulting from nephritis are present the 
disease will be shown by such examination, and we shall thus be able to 
differentiate it from tubercular meningitis. 

(9) Cerebro-Spinal Meningitis. — It is often quite difficult to differen- 
tiate the early stages of tubercular meningitis from those of cerebro-spinal 
meningitis. In typical cases, however, the diagnosis is easily made, as the 
long prodromal period of tubercular meningitis, as a rule, does not occur in 
cerebro-spinal meningitis, and the temperature in the latter disease is almost 
always high, while in the former it is, as I have already told you, raised to 
only a moderate degree. In fact, all the symptoms of cerebro-spinal men- 
ingitis are markedly acute in comparison with those of tubercular menin- 
gitis, which is essentially a disease of a subacute character. I shall pres- 
ently show you a case of tubercular meningitis (Case 272, page 618) which 
simulated cerebro-spinal meningitis very closely. 

(10) Non- Tubercular Meningitis. — On closely studying what I have 
already told you of the symptoms of meningitis in general, you will be 
able in the great majority of cases to differentiate it from other diseases, 
provided that you do not attempt to make the diagnosis too early. Re- 
member that you are seldom warranted in making an early diagnosis, in 
view of the wide range of possible nervous symptoms which can be met 
with in young children. Having determined that the disease is of cerebral 
origin, we must next differentiate between the tubercular and non-tubercu- 
lar forms of meningitis by means of the broad rules of which I have just 
spoken, and which I have condensed and simplified by means of this table 
(Table 101, page 612). 



612 PEDIATRICS. 



TABLE 101. 



Cerebral Meningitis. 
Non-tubercular. Tubercular. 
Usually secondary (possibly primary). Secondary. 
Not hereditary. Hereditary. 
Acute. Subacute. 
Prodromata short, if any. Prodromata long, decided. 
Headache severe at once, with delirium Headache less severe at first, but gradually in- 
early, and soon followed by somnolence. creasing ; delirium less common and milder. 
Photophobia extreme. Photophobia not so marked. 
Convulsions violent. Convulsions less violent. 
Temperature high. Temperature moderate. 
Pulse and respiration rapid. Pulse and respiration slow and irregular. 
Duration short. Duration long. 

Transudation into the ventricles may occur in either form. The younger 
the infant the nearer the two forms approach each other in the similarity 
of their symptoms. Caille has lately shown the value for diagnosis of 
Quincke's method of tapping the spinal canal. 

Infantile Tubercular Meningitis. — According to some extended 
observations made at the hospital in Stockholm, infantile tubercular menin- 
gitis is characterized in the first year by an absence of prodromata, the 
sudden development of acute symptoms, a short course, and a fatal issue. 
The temperature is high, 38.8°-39.4°-40° C. (102°-103°-104° F.). The 
respirations are quickened and comparatively regular, 30-40-50. The 
pulse is high, 130-140-150. Clonic spasms and strabismus often occur. 
Paralysis is quite frequent, and diarrhoea is present rather than constipation. 
Bulging of the fontanelles is usual. Sinking of the abdomen is rare. 
Vomiting may occur, but is not especially common. Sharp cries are occa- 
sionally met with. The differential diagnosis from non-tubercular menin- 
gitis is difficult. Sopor and coma at the end are frequent in both diseases. 
The duration is seldom more than a week. It may be only two days, yet 
in rare cases the infant, like the child, may live for a month. 

During the second year the symptoms of tubercular meningitis become 
of rather an irregular type, sometimes assuming the character of those 
which are seen in the first year, but soon corresponding more nearly to 
those which are met with in the middle period of childhood. 

Prognosis. — Where we are sure of our diagnosis, I believe that in our 
prognosis we should give no hope of recovery Avhatever, except that in the 
extremely rare cases which I have just mentioned a temporary remission 
may take place. The reported cases of absolute recovery from tubercular 
meningitis cannot but be looked upon with scepticism. Indeed, the non- 
tubercular forms of meningitis simulate the tubercular so closely that without 
post-mortem verification recoveries can be supposed to be possible, but can 
hardly be accepted as proved. 

Treatment. — The treatment of tubercular meningitis up to the time 
when the diagnosis is established should be purely symptomatic ; later we 



OEGANIC NERVOUS DISEASES. 613 

should make the child comfortable by every means in our power. As no case 
of tubercular meningitis has ever been proved to be cured by iodide of potas- 
sium or any other drug, it is useless and unwise to encourage ourselves and 
the parents by false hopes of good results arising from the administration of 
any drug whatever. Up to the present time our knowledge of the disease 
justifies us only in using drugs as palliatives for the child's suffering. 

The following case illustrates very well the tubercular meningitis of 
middle childhood : 

A boy (Case 270), five years old, had always been well and strong. On December 3, 
while endeavoring to climb into bed, he fell and struck the back of his head. He cried 
afterwards, but the blow left no mark, and nothing was thought of it. The following day, 
while playing, he fell and struck the back of his head, but the blow was no more serious 
than he had often had before. On the next evening he went to a children's party, ate 
nothing unusual, went to bed early, and slept all night. On the following day he was 
unable to eat and was somewhat fretful, both of which conditions were unusual for him. 

On December 29 he had a slight follicular tonsillitis. His pulse and temperature were 
normal, the cheeks were flushed, the eyes dull, and the pupils normal. His head was 
slightly hot, and he was dull and drowsy. He did not have any movement of the bowels for 
two days, but on the third day the}^ were moved b}" means of medicine. He continued to be 
in about the same condition until January 2, when his temperature was 37.2° C. (99° F.), 
and his pulse 64, regular and strong ; his face was flushed, and his eyes were vacant and 
staring. He vomited once on that night, passed his water involuntarily, moved his left leg 
spasmodically, and clinched his hands occasionally. He was evidently uneasy, and moaned 
a good deal. 

On the following day the pulse was occasionally intermittent. In the mean time he 
became more and more drowsy, and finally relapsed into a state of unconsciousness. 

On the 8d of January the pupils were normal, but he was completely unconscious. 
The temperature was 88.1° C. (100.6° F.), the pulse 180, and the respirations 30. 

I saw the child on January 4, and on making a careful physical examination found 
nothing abnormal, except a slight congestion of the ear in the neighborhood of the malleus, 
and in the back over the apex of the lung was a slight elevation of pitch on percussion. 
The temperature was 39.1° C. (101.2° F.), and the pulse was 89 and strong. There was 
considerable twitching of the arms, chiefly on the right side, lasting from ten to twenty 
minutes. The pupils were slightly contracted, but were alike. That night he drew his 
right hand across the face with a quick trembling motion, the right leg being drawn up 
and the whole body trembling ; occasionally there was moaning and sighing respiration. 

Dr. C. J. Blake, who examined the ears, reported that there was a slight congestion in 
the posterior canal of both ears and also in the neighborhood of the right malleus. Both 
membranas tympani were clear, normal, transparent, and without injection of the manubrial 
blood-vessels. There was, in fact, no evidence of disturbance of the ears. On the posterior 
wall of each external auditory canal at the anterior third, more pronounced in the right than 
in the left ear, was a circumscribed patch of injection such as is observed in cases of inflam- 
matory process in the mastoid antrum, and occasionally uncomplicated congestion of the 
middle ear. Dr. Blake thought that the congestion was merely a symptom of the meningeal 
congestion and was not the cause of the disease. 

During the next few days the boy's condition varied but little. The eyes, usually 
closed, would at times open completely, when the eyeballs could be seen to move from side 
to side. The respiration was sighing, interrupted, occasionally almost inaudible, and then 
for a time noisy. At times the breathing was suspended for several minutes, when bright 
red spots would appear on the cheeks ; these would disappear when the respiration was re- 
sumed. The patient moaned occasionally, and there was some twitching and moving of the 
extremities, but no convulsions. The pulse was fair in strength, but at times intermittent. 
The temperature varied, but was moderate in degree. 



614 PEDIATRICS. 

The extremities of the right side were absolutely motionless, and sensation was appa- 
rently absent. The child lay, as a rule, perfectly quiet, as though asleep, and at times 
would present the picture of a perfectly healthy child sleeping. 

On January 9 the extremities became cold, the face very pale, and the pulse impercep- 
tible. This condition lasted fifteen minutes, when he improved in appearance. During the 
night the breathing grew very rapid, he was restless, moved the left arm continually, and 
moaned. After some time he opened his eyes, looked around the room, and then became 
quiet and slept. The next day he was slightly unconscious, and the fingers were flexed, with 
a very strong contraction of the muscles. The breathing then became more difficult, the 
nostrils being widely dilated with every breath. During the night he was conscious for 
some time, swallowed water without difficulty, and the eyes were wide open. 

On January 11 there was ptosis of the right eyelid. The pulse became regular, com- 
pressible, and intermittent. The left arm was occasionally raised to the head with a quick 
spasmodic motion, the child moaning as if distressed. Later the eyes became fixed, the 
pupils dilated, the nostrils expanded, and a bluish color appeared around his mouth and nose. 
The breathing became very difficult. During an attack of this kind he had every appear- 
ance of being moribund, and each attack was thought to be his last. 

The change from day to day in the child's general condition was almost imperceptible. 
He was, however, gradually becoming emaciated. 

On January 12 the pupils of both eyes were much dilated ; the right eye was almost 
motionless, with ptosis of the right lid, while the left eye moved occasionally from side to 
side in a circle. The face was livid, and the hands were mottled with bright red spots. 
Later, the left eye became quiet and had a slightly contracted pupil. 

On the following day, January 13, the movements of the left eye were repeated, the 
right pupil being dilated, while the left one was contracted. During all this time the 
enemata were retained, the bowels moved regularly, and the urine was passed normally. 
The pulse was so weak that at times it could not be found at all at the wrist, and the 
breathing was at times inaudible and almost imperceptible. 

On January 17 there was slight discharge of pus from the mouth, and also from the left 
eye. During the next day his breathing grew more and more difficult, and it seemed as 
though he could not possibly live much longer. In the evening, however, his respiration 
was much easier and his whole appearance was greatly improved. His breath was very 
oflensive, and there was a loud bubbling sound in the throat. 

On January 19 the right nostril was much more dilated during inspiration than the left. 
The forehead was shiny and slightly (edematous, and the veins were plainly mapped out. 
Occasionally he moved his right hip-joint and shoulder, which had been motionless for days. 
There was another slight discharge of pus from the mouth, and when his lips were wiped he 
seemed more sensitive to touch than before. During the night his left arm and left leg 
were constantly moved, and he moaned as though he were still in pain. His forehead was 
still cfidematous. 

During the next day he was in a state of deep coma for four hours. He then drew a 
deep sigh and seemed somewhat conscious. The pulse was soft, intermittent, and fluctu- 
ating. 

On January 20 he partly opened and shut his right eye, which was very sensitive to 
light. The breathing was difficult and noisy. The face was covered with perspiration. At 
10 P.M. the sighing respiration began again, and at 10.15 he died quietly, on the thirty-first 
day of the disease. 

The autopsy was made eighteen hours after death by Dr. W. W. Gannett, and the 
report was as follows : 

The body was much emaciated. There was slight lividity of the dependent portions. 
Eigor mortis was present. Nothing unusual was observed about the calvaria or dura 
mater. The sinuses of the latter contained partly congested blood. The pia mater of the 
convexities of the brain was very dry, and the minute vessels were injected. The convo- 
lutions were flattened. The sulci were obliterated. The pia of the base along the chiasma 
and in the fissures of Sylvius was thickened, and there was an opaque yellowish-gray color 
from the presence of a fibrino-purulent material in its meshes. In the above situations, 



ORGANIC NERVOUS DISEASES. 615 

also on the under surface of the frontal and temporal lobes, also on the pons and inner 
borders of the occipital lobes, were to be seen very numerous, gray, translucent nodules 
about 2 mm. {^^ inch) in diameter. The lateral ventricles each contained about 60 c.c. 
(If ounces) of a slightly opaque fluid. The ependyma was thick, grayish, and opaque. 
The choroid plexuses and velum interpositum were markedly injected. In the latter were 
to be seen several small nodules similar to those described in connection with the pia of the 
base. 

A section of the hemispheres showed nothing remarkable, the puncta cruenta being of 
about the usual size and number. 

The basal ganglia, pons, medulla, and cerebellum also showed no appearances worthy 
of special note. 

The heart was normal 

The pleural surfaces on both sides were free from adhesions ; the pleural cavities con- 
tained no fluid. 

Both lungs retracted readily, and were crepitant everywhere except at the apices, where 
small nodules could be felt within the tissue. 

On section an opaque, grayish-yellow, cheesy nodule, 6 mm. (^ inch) in diameter, 
surrounded by a narrow border of gray and translucent tissue, was found at the top of the 
left lung. At the top of the right lung were several closely aggregated nodules of a similar 
appearance, forming together a mass about 2.5 cm. (1 inch) in diameter. The other por- 
tions of the lungs were normal. 

The bronchial lymph-glands were enlarged to 1.2 cm. (^ inch), showing on section a 
yellow, opaque, crumbling material. 

The spleen was of the usual size, color, and density. On section the follicles and 
trabecule were found to be fairly distinct ; the pulp was firm and of a pale red color. Two 
or three gray, translucent, sharply defined, slightly projecting nodules, 1 mm. (J^ inch) in 
diameter, were to be seen. The kidneys were normal. In the lower third of the ileum a 
loss of substance of the mucous membrane was found in several places. The edges of these 
lesions were elevated and their bases granular. The liver was found to be normal. 
The pathological diagnosis was — 
Tubercular meningitis. 
Acute hydrocephalus, 
Ependymitis, 

Tuberculosis of the velum interpositum. 
Tubercular nodules in the lungs, 
» Tuberculosis of the bronchial lymph-glands, 

Tuberculosis of the spleen, 
Tubercular ulcerations of the intestines. 

I have here in Bed 3 an interesting case of tubercular meningitis to 
show you. 

This boy (Case 271) is three years old. There is no history of tubercular or syphilitic 
disease in the parents. 

Three weeks before entering the hospital, the child, who had previously been healthy, 
began to complain of pain in the abdomen, and to have anorexia and a feeling of general 
malaise. Somewhat later it was noticed that the eyes would at times turn inwards and that 
the head would be drawn back. He was in this condition for two weeks before entering the 
hospital. 

On March 13 he was brought to the hospital, and was found to have a temperature of 
38.4° C. (101.2° F.), a pulse of 120 and not intermitting; the respirations were 40. He 
was in an unconscious and drowsy condition. His head was drawn back, and he did not 
wish to lie on his back. The tongue was not coated. An examination of the heart, lungs, 
and urine showed nothing abnormal. An examination of the eyes, made by Professor O, 
F. Wadsworth, showed the pupils to be dilated, but equal in size and reacting to light. 
There was internal strabismus of both eyes. There was optic neuritis and the beginning of 



616 PEDIATRICS. 

an atrophy following the neuritis. The patellar reflexes were absent, and there was no 
ankle-clonus. The superficial reflexes were normal. There was no tenderness of the head 
or spine. An examination of the ear, which was made by Professor J. O. Green, showed 
nothing abnormal. 

On March 16, as you remember, I examined the child before you with Dr. BuUard. 
At this time he showed nystagmus with conjugate deviation to the right or to the left, 
according to the side on which he lay. No tache cerebrate was found. 

On the 17th an erythematous congestion was noticed on the right cheek, and he became 
still more somnolent. 

Case 269. 




Tubercular meningitis. Male, 3 years old. 

On the 18th the head was much less retracted. He had vomited once during the night 
and once in the morning. 

On the 21st he had a convulsion, which was the flrst that had occurred during the 
course of the illness. He was also found to have partial opisthotonos. The legs did not 
participate in the contraction, but the head was drawn back almost to the buttocks. He 
was found to have Cheyne-Stokes respiration. During this day he had four or flve con- 
vulsive attacks, and remained in a condition of opisthotonos in the intervals between the 
attacks. These convulsive attacks lasted about half a minute each, and the intervals be- 
tween them were about four minutes. There was incontinence of urine and of faeces. The 
pulse was rapid and irregular, and the extremities were cold. The tache cerebrate was 
obtained on this day, and lasted for twelve minutes. 0.12 gramme (2 grains) of chloral and 
2 grammes (^ drachm) of brandy were given subcutaneously. The convulsions ceased, the 
opisthotonos disappeared in twenty minutes, and the child remained quiet. 

On the 26th the record was that for two days the child had been decidedly better, the 
retraction and strabismus were less, the nystagmus had disappeared, and he had recognized 
and spoken to his father. The tache cerebrate could be obtained, but was less distinct, and 
the temperature was normal. 

On the 28th he became worse again. His head was again retracted, but he was not 
wholly unconscious. There was retention of urine, for which he had to be catheterized. 

On the 29th he had a convulsion lasting three minutes, in which the right arm was 
jerked up over his head. This was followed by partial opisthotonos, and then by a general 
convulsion lasting two or three minutes, during which his eyes rolled up. At times he 
would have convulsive movements and tremor without actual convulsions. 

To-day (April 7), as you will notice, the right hand lies motionless by his side and is 
in a state of extreme pronation. He is unconscious, and all the abnormal symptoms have 



ORGANIC NERVOUS DISEASES. 617 

returned. You see that he has the characteristic aspect of a typical case of tubercular 
meningitis. The eyes are open and staring, the head is drawn back, the abdomen is 
retracted, and on drawing the finger over the thigh you see the tache cerebrate is very 
marked. The respirations are of the Cheyne-Stokes type, the pulse is intermittent. The 
temperature has varied from 37.2° to 38.8° C. (99° to 102° P.), but has risen within the last 
twelve hours to 40° C. (104° P.), which indicates that the fatal issue of the case is very 
near. 

(Subsequent history of the case.) On the following day there were a number of con- 
vulsions occurring in rapid succession, especially involving the left side. The child groaned 
and sighed a number of times ; his arms and legs were rigid, his eyes were rolled upwards. 
At two o'clock in the morning he took some milk, but after that refused it, and from that 
time until his death, at 7.25 a.m., he was in a condition of continued convulsions. 

I shall now ask you to come to the autopsy-room, in order that you may 
see the results of the post-mortem examinations of some children who have 
died of tubercular meningitis. Dr. Gannett has some specimens here to 
show you of a case which has just died in the hospital. When the patient 
was alive the case simulated cerebro-spinal meningitis very closely, and you 
have already seen it in the wards. It is a very instructive case, as it is an 
unusual one, and illustrates an important fact in connection with tubercular 
meningitis, — namely, that the patient may recover temporarily from an 
attack of the disease and finally die of a recurrent attack. This is, how- 
ever, a very rare occurrence. 

You may remember that when this infant (Case 272) was alive I explained to you the 
difficulties which may arise in making a definite diagnosis in cases where cerebral symptoms 
are present. 

It was twenty-one months old when it entered the hospital. The history obtained 
from the mother was that she had always been healthy, but that the father was supposed 
to have had the primary lesion of syphilis three years previously, although no secondary 
manifestations had appeared. The infant was born after an unusually long labor with a 
prolonged forceps delivery. 

It was stated to have been healthy until it was nine months old. At that time it had 
a convulsion, which first afiected the right and then the left side. It was unconscious for 
ten days, and was somnolent for four weeks. Two or three weeks later its general condition 
improved. During this time the infant did not use the muscles of its left side or limbs, 
and it could laugh only with the right side of its face. Its body was turned continuously 
to the left ; sensation was not interfered with. It gained slowly in strength, and the symp- 
toms gradually disappeared, until it was thirteen months old, when it seemed to be com- 
paratively well, all motor disturbances having ceased. In the following months it had 
a few slight attacks of the same nature. The final attack from which it died occurred 
when it was twenty months old, and began with a convulsion on the right side with 
twitching of the muscles on the left side and frothing at the mouth. There was also 
ptosis of the left eye. It did not cry out when going into the convulsions, but had marked 
opisthotonos, which lasted, to a greater or less extent, for five weeks. During these five 
weeks it was unconscious, and there were several slighter attacks. 

On entering the hospital, physical examination showed that the infant was of me- 
dium size, pale, poorly developed and nourished, and unable to s^and, the left leg being 
weaker than the right. Nothing abnormal was found in connection with the heart or 
lungs. She could use her extremities partially, but there was an evident motor disturbance 
of the whole of the left side, and she took hold of objects with her right hand only. The 
index and little finger of the left hand were frequently found to be extended, the second and 
third fingers being flexed partially. There was also slight drooping of the left eyelid, and 
the lines of the left side of the face were obliterated. There was a very slight drooping of 



618 



PEDIATRICS. 



the left corner of the mouth. There was slight strabismus of the left eye, and an apparent 
lack of power of the left external rectus muscle. The patellar reflexes were exaggerated 
on the left side. Examination of the ankle-clonus was negative. The epiphyses of the 
wrists were somewhat enlarged. The child could not speak, and apparently could not 
understand readily. No evidence of a history of cerebral injury could be obtained. The 
circumference of the chest was 1 cm. (f inch) larger than that of the head. The cause of 
the disease was so obscure that at this period the diagnosis could not be definitely made, the 
supposition being that the child was suffering from the results of an attack of cerebro-spinal 
meningitis, or possibly from tertiary syphilis, or that a cerebral hemorrhage had taken place, 
with a resulting spastic paralysis. 

While in the hospital the child presented a number of different nervous phenomena. 
At times she would appear to be for days semi-comatose and would not take notice of any- 
thing about her ; the eyes rolled up and she would have slight twitching of the body, but 
this was not localized, and there were no convulsions. At another time, while sleeping 
quietly during the night, she was found to be unconscious in the morning, and to have her 
head slightly drawn back and her eyes turned up. Nystagmus was present, and the pupils 
were dilated and did not react to light, but were equal in size. Clonic twitching of the 
right foot and the muscles of the right side, flexion of the fingers of the right hand over 

Case 272. 




Recurrent tubercular meningitis. Female, 21 months old. 



the thumb, and twitching of the muscles of the wrist sometimes occurred. There was 
twitching of the fibres of the sterno-mastoid muscle on the right side. There was also 
twitching of the right side of the face. There was no spasm on the left side, except of the 
left sterno-mastoid, but there was a nystagmus of the left eye. These clonic twitchings 
were rhythmical and occurred 180 times a minute. The pulse was 172, and was very 
feeble. The respirations were 80, rapid and rattling ; the temperature was 39.4° C. (103° F.). 

From 2 a.m. until 5 a.m. 0.36 gramme (6 grains) of chloral was given by enema, and 
0.86 gramme (6 grains) of bromide of potassium was given every three-quarters of an hour 
by the mouth, alternating with the chloral. The spasms became less marked after 3 a.m., 
but continued in a mild degree up to 11 a.m. During the remainder of the day the child 
lay in a stupor, but had no convulsions. It was able to swallow brandy and milk, which 
were given to it by the mouth in small quantities at different intervals. 

On the day following this attack the report was that the child had slept well, and that 
there was more or less stupor, but there had been no convulsions. 

On the following day the condition remained about the same, but on the next day she 
apparently had attacks of pain, when she would straighten herself out, throw back her 
head, and cry out. 

On the following day, about 11 a.m., she began to have the same twitchings as in the 
attack previously mentioned. They were of the same character, except that the extensor 



ORGANIC NERVOUS DISEASES. 619 

muscles of the left foot contracted feebly. The convulsions ceased at about 2 p.m., and 
the child remained in a stupor. 

On the following day it was reported that she had had no convulsions, but apparent 
attacks of pain, when she would cry out and throw her head back, and that she had had 
an attack of opisthotonos, in which condition you will remember you once saw her. This 
condition of opisthotonos at times would be much more marked than when you saw her, 
so that the heels would almost touch the back of her head. The next symptom which 
appeared was stupor. The temperature at this time was considerably elevated. 

On the following day there were no convulsions, and her condition was about the same 
as on the previous day, but the head was drawn back and was rigid, and the legs were drawn 
up and were held rigidly. She lay in this condition, most of the time in a stupor, crying 
out occasionally, and moving her left hand and arm more than she did the right. At times 
she would appear to be sleeping naturally and the rigidity would pass away. 

The opisthotonos gradually became more marked and more frequent in its occurrence, 
and, although the bowels were moved regularly every day, she took less nourishment, and 
the temperature continued to rise, and varied from 37.7° to 40° C. (100° to 104° P.). 

The time when you saw her in the condition of opisthotonos was the sixth week from 
the time of this last attack. During the last week of her life the opisthotonos became less 
marked, and at times passed away entirely. She opened her eyes, but the pupils reacted 
very slightly. The left pupil became somewhat larger than the right and reacted slightly, 
while the right pupil did not react at all. The spastic condition of the right wrist and left 
knee persisted, the patellar reflexes were equal and normal, and the child lay in a semi- 
stupor, with a temperature varying from 38.3° to 39.4° C. (101° to 103° F.). She took less 
and less nourishment, and had a slight cough. She gradually lost in weight and became 
weaker, and on the day before she died her respirations for a time were very rapid, running 
up to 100 a minute. Death took place apparently from exhaustion. 

The long duration of this last attack, embracing a period of eight or nine weeks, made 
the diagnosis very difficult, and prevented us from making the clinical diagnosis of tubercu- 
lar meningitis, which these specimens just found at the autopsy prove to be the disease by 
which the child was affected from the beginning. 

This chart (Chart 21, page 620) represents the temperature, pulse, and respirations of 
this case during the last twenty-one days of its life. 

On examining the brain you see that the dura mater is normal, the pia mater of the 
convexities is pale, and the cerebral convolutions are somewhat flattened. The pia mater 
at the base of the brain shows considerable infiltration with fibrin, which is quite firm, but 
there is little or no injection of the blood-vessels. In many places in the portions of the pia 
mater at the base of the brain where the meshes of the pia are not infiltrated with fibrin, 
gray nodules as large as a pin-head are to be seen. The lateral ventricles are at least six 
times the usual size, the layer of brain-substance between the cavity and the convexity being 
considerably thickened. The ependyma of the lateral and fourth ventricles is thickened 
and granular. On section the brain-substance is found to be pale, and the puncta cruenta 
small. Sections of the basal ganglia, pons, medulla, and cerebellum show that the brain- 
substance is normal. The spinal cord shows in gross nothing unnatural. The heart is 
normal. Beneath the pleura of both lungs numerous gray nodules the size of pin-heads are 
to be seen. At the apex of the left lung is a cheesy nodule 0.5 cm. (^ inch) in diameter. 
Both lungs are extensively studded with gray miliary tubercles. The spleen and kidneys 
show similar appearances, and the bronchial and lymph glands are very much enlarged and 
show throughout their substance cheesy degeneration. 

The pathological diagnosis in this case is— 
Subacute tubercular meningitis, 
Chronic granular ependymitis. 
Chronic hydrocephalus. 
Atrophy of the brain-substance, 

Miliary tuberculosis of the lungs, spleen, and kidneys, 
Chronic tuberculosis of the lung. 

As Dr. Gannett has explained to you, some of the tubercular lesions are of recent 



620 



PEDIATRICS. 



growth, while others are evidently old ones and representative of a former attack. You 
see. therefore, that the presence of older tubercular lesions in the meninges, as well as of 

CHAKT 21. 





Days of Disease in Last Attack. 




F. 


36 1 37 


38 1 39 


40 


41 


42 


43 


44 


45 


46 


47 


48 


49 


50 


51 


52 


53 


54 


55 


56 


c. 


107= 
106^ 
105° 
104° 
103^ 
102° 
101° 
100^ 
99° 

NORM'L 

TEMP. 

98° 

97' 

96^ 
95' 


ME 


xME 


ME 


ilE 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


41.6° 

4i.r 

40.5° 

40 0° 

39.4° 

38.8° 

38.3° 

37.7° 

37.2° 
37.0° 
36.6° 

36.1° 

35.5° 
35.0° 








































































































i 
























1 












A 




/ 


/ 




J 




















1 


/ 




j^ 


\ 


y 


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/ 


/ 






/ 












/ 








V 


/ 


/ 


\ 




/ 


V 




/ 






/ 




/ 


/ 




/ 


/ 


/ 








/ 




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If 






1/ 


Li 


/ 


1/ 


/ 


/ 


1 


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1/ 




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1 




/ 


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/ 










































































































































































A 


1 






































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150 
140 

130 
120 
110 
100 
90 
80 
70 


T 
















1/ 


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— 






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1 




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/ 










































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50 

45 

40 

35 

30 

25 

20 
15 


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.|. 


1 


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Recurrent tubercular meningitis. Last 21 days of life. 

those which produced the symptoms in the last attack from which the infant died, proves 
to us that the case is one of recurrent tubercular meningitis. 



These cases of recurrent tubercular meningitis are rather rare, and the 
disease is so uniformly fatal in the first attack that I shall recall to your 



ORGANIC NERVOUS DISEASES. 621 

minds the case which was under Dr. Townsend's care at the Good Samaritan 
Hospital. 

A little girl (Case 273), five years old, entered the Good Samaritan Hospital with hip- 
disease on the left side and dorsal Pott's disease. She was treated in bed for these diseases, 
and did very well for a time, but on May 7, after a week in which she showed anorexia 
and loss of weight, she began to vomit, and on the following day she complained of head- 
ache and photophobia. She rolled her head from side to side. Her bowels were consti- 
pated, and could not be moved by enemata, and her abdomen was much retracted. This 
continued for four days, with at times delirium, accompanied by marked drowsiness. There 
were also ptosis of the left eyelid, slight convulsive movements of the limbs, and frequent 
putting of her hands to her head, as though she were in pain. 

On May 12 she had recovered so much that she played with the other children and 
called for her books and toys. The left pupil, however, remained a little smaller than the 
right. 

On the 15th of May, and again on the 20th, 21st, 25th, and 27th, the patient became 
drowsy, and complained of headache. In the intervals between these attacks she seemed 
bright and well. During the drowsy periods her abdomen was retracted and her bowels 
were constipated. 

From the 27th of May until the 20th of July she appeared as well as usual. On the 
latter date her temperature suddenly rose to 40.1° C. (104.2° F.). She had pain in the 
head and photophobia, and the right pupil was larger than the left. This lasted only two 
■days. She then became bright and well again, and continued so for over ten weeks. 

On October 2, having been perfectly well on the previous day, she began to vomit and 
to complain of headache. Two days later she fell into a stupor and became completely 
comatose. 

On October 6 the left pupil was widely dilated and the right one was contracted to the 
size of 2 mm. (J^ inch) ; there were convulsive movements, and later in the day she died. 

The post-mortem examination showed a recent tubercular meningitis. In addition to 
these lesions there were found some older large tubercles of the brain and the remains of the 
previous attacks of tubercular meningitis. 

Nothing else of importance was detected in the other organs. 

I will now ask you to return to the wards, to see a case of tubercular 
meningitis in a child, two and a half years old, who entered the hospital at 
what was supposed to be about the tenth day of the disease. 

The history of the case (Case 274) is that the father's mother and the mother's mother 
:and brother died of consumption. "When this child was one year old he had measles, other- 
wise he had always been well. About two or three weeks ago it was noticed that the child 
:slept more than usual. At that time he appeared to be feverish and his tongue was noticed 
to be coated, but there was no nausea nor vomiting. A few days later he vomited once or 
twice during the day. The bowels were constipated. Eight days before entering the hos- 
pital he had a slight convulsion, and three days later he cried a great deal, as if he were 
in pain. Two days before entering the hospital he had a number of convulsions during 
the night, each lasting about ten minutes. On the following day the convulsions occurred 
again. On the day he entered the hospital he began to have convulsions at three o'clock, 
which lasted about two and a half hours. He was also noticed to have marked internal 
strabismus of the left eye and slight strabismus of the right eye. The muscles of the neck 
-were somewhat contracted. There was no paralysis of the extremities. 

The pupils were equal, they reacted to light, and were somewhat dilated. The con- 
junctivae were injected, the left one especially so. Sensation was not impaired. The knee- 
jerks and ankle-clonus were absent. There was a marked tache cerehrale. The respirations 
were irregular and sometimes of the Cheyne-Stokes type. The child was unconscious and 
was very pale. The heart was found to be beating very rapidly, sometimes as high as 200 



622 



PEDIATRICS. 



beats in a minute. No souffles were detected. The temperature was 38.3° C. (101° F.). 
During the next day the child lay in a state of stupor. He continually moved the left 
forefinger and thumb, kept drawing the head to the left, and was very restless. He was 
reported to have cried all night and to have put his hand to his left ear. He lay with 
his eyes wide open, took nourishment well, and had less strabismus than when he entered 
the hospital. On the following day (about the thirteenth day of the disease) he was very 
restless, had sordes on the teeth, and his tongue was very dry. Examination of the ears 
showed nothing abnormal. The abdomen was somewhat retracted. He was less restless, 
and slept a good deal. The bowels were moved regularly, and the movements appeared to be 
well digested. He took about 90 c.c. (3 ounces) of milk every two hours. On the follow- 
ing day there was no especial change, except that the muscles of the neck were firmly 
contracted and the tache cerehrale came out more slowly than on the previous -day. A 
slight paralysis of the left side of the face appeared on this day. The left eyelid moved 
rather slowly, and the left corner of the mouth seemed to drop a little. The pulse was 
irregular, of fair strength, and intermittent. He did not take his nourishment so well. 
Yesterday the child was in about the same condition. 

To-day you see that he is lying in a comatose condition, with his eyes half closed. 
The pupils are rather irregular, dilated, and do not respond to light. The face is somewhat 
cyanotic, especially about the nose and the eyes. The respiration is decidedly of the 
Cheyne-Stokes type. The pulse is irregular and intermittent. On drawing my finger 
over his thigh you see that the iache cerebrate is well marked and that it lasts about ten 
or fifteen minutes. The head is somewhat drawn back. What I wish especially to call 
your attention to is the temperature chart (Chart 22). You will notice that the tempera- 









CHAKT 22. 










Days of Disease 




F. 


10 


11 


12 


J3 


14 


15 


16 


17 


c 


107° 
106° 
105° 
104° 
103° 
102° 
101° 
100° 
99° 

NORM't 

TEMP. 

98° 

97° 

96° 
95° 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


41.6° 

41.1° 

40.5° 

40.0° 

39.4° 

38.8^ 

38.3° 

37.7° 

37.2° 
37.0° 
36.6° 

36.1° 

35.5' 
35.0° 
































/ 
















/ 
















/ 






































^ 


1/ 


\ 






/ 












v\ 



























































































Tubercular meningitis. Male, 2>^ years old. 



ture had risen yesterday from 37.5° C. (99.5° F.) to 39.5° C. (103 2° F.), and that it is now 
rapidly rising until it has reached 41.1° C (106° F.). 

This rise of temperature is very significant, and denotes that the child will die very soon. 

(Subsequent histoiy.) The child died quietly on the evening of what was supposed to 
be the seventeenth day of the disease. 

The autopsy was made by Dr. Mallory. Eigor mortis was present ; the left pupil was 
dilated ; there was moderate lividity of the dependent portions of the body. 

Heart. — The right ventricle was dilated and contained dark, clotted blood. The valves 
were normal. 



ORGAXIC X'ERVOUS DISEASES. 623 

Lung's. — A number of small, flattened, gray masses were found in the pleura ; on 
section they were found to be miliary tubercles. The right lung was adherent to the 
parietal pleura by strong fibrinous adhesions, beneath which were miliary tubercles, especially 
in the areas covering the ribs, the diaphragm, and the upper third of the sternum. A small 
number were also found in the substance of the lung. The bronchial glands were enlarged, 
one of them being 1.2 cm. [^ inch) in diameter. This gland on section was yellow and some- 
what broken down. 

Spleen. — The spleen was of about normal size and showed many flattened miliary 
tubercles. Beneath the capsule, on section, there were found numerous tubercles of varying 
size : the larger ones were yellow and the smaller ones gray. 

Peritoneum. — There were found scattered all through the omentum, on the surface 
of the root of the mesentery, over the bladder, and particularly on the under surface of the 
right side of the diaphragm, numerous miliary tubercles. The lymph-glands of the mesen- 
tery were considerably enlarged, particularly beneath the stomach. On section they showed 
tubercles, most of which were quite large and had yellow, cheesy centres. 

Intestine. — In the intestine about the ileo-caecal valve there were several small ulcer- 
ations apparently in the process of repair. In the caecum there were two narrow ulcers 
about 1.0 cm. (f inch) long. The bases were injected. The walls were not broken down. 

Liver. — Many rather large tubercles were found beneath the capsule of the liver. 
They were flat, but not cheesy. 

Brain. — The convolutions of the brain were flattened. There was marked fibrino- 
serous exudation at the base of the brain, covering the optic commissures and the adjoining 
parts. The third nerve was chiefly injected. Many small tubercles were present in the fis- 
sures of Sylvius and over the convexities of the brain. In the right half of the cerebellum, 
just beneath the pia, about the centre of the base, was a yellow nodule about 6 mm. (^ inch) 
in diameter. In the left lateral ventricle anterior to the velum interpositum was a similar 
nodule about 3 mm. (^ inch) in diameter projecting into the ventricles. Both ventricles 
were moderately dilated by the serous fiuid. The ependyma was everywhere granular : 
this condition was due to small, gray, transparent tubercles, No tubercles were found in the 
third or fourth ventricles. 

Kidneys. — The kidneys contained a few rather large grayish areas with here and there 
a yellowish speck. 

The pathological diagnosis of the case was — 
Old tubercular ulcers of the intestine, 

Chronic tuberculosis of the mesenteric and bronchial lymph-glands. 
Solitary tubercle of the brain, 

Miliary tuberculosis of the pia, lateral ventricles, pleura, lung, spleen, kidney, 
peritoneum, and liver. 

In connection with the other cases of tubercular meningitis which I 
have spoken of, I shall now" mention some cases which represent the earlier 
periods of life, when, as I have told you, we are led to expect a variation in 
the symptoms and a consequent difficulty in the diagnosis. The first two 
cases represent tubercular meningitis as it so often appears w^hen occurring 
in infants under one year. 

The first case was seen by me in consultation with Dr. Kimbal, of 
Salem. 

A male infimt (Case 275), ten months old, had always been well and strong. For a 
few days before I saw him he had been rather dull and feverish, but had shown no other 
abnormal symptoms. He was evidently cutting some teeth at that time. On the day that 
I saw him, except that he was somewhat fretful and that he put his hands to his mouth as 
though his gums were disturbing him, he seemed very well, and careful physical examina- 
tion revealed nothing abnormal in the ear, throat, chest, or abdomen. 



624 



PEDIATRICS. 



On the day following my visit the slight symptoms of indisposition which he had 
previously shown disappeared, and he played with a toy whistle, blowing it himself, and 
seeming to be very well. This condition lasted for two or three days, when he became 
stupid and unconscious, and about the tenth day from the time that I saw him he died in 
convulsions. 

This case should impress upon you the difficulty of making a diagnosis in the early 
period of a tubercular meningitis, and how guarded we should be in giving a prognosis in 
young infants, even where the character of the disturbance is very slight. 

The next case (Case 276) was the infant, eleven months old, whom I examined before 
you on the 13th of March. 

CHAET 23. 





Bays of Disease 




h\ 


1 


2 


3 


4 


5 6 


7 


8 9 


10 


c. 


107° 
106° 
105° 
104° 
103° 
102° 
101° 
100° 
99° 

NORM'l 

TEMP. 

98° 

97° 

96° 
95° 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


41.6° 

4i.r 

40.5° 

40.0° 

39.4° 

38 8' 

38.3° 

37.7° 

37.2° > 
37.0° 
36.6° 

35.1° 

35 5° 
35.0° 






























t 


















/ 


^ 






\y 


/ 


\ 






1 


/ 




/ 




V 


/ 




/ 


A 


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i' 














/ 


V 


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/ 











































.... 




..... 




..-., 





'■- 



































































150 

140 

130 , 

120 

110 

100 

90 

80 

70 
.60 






















^ 












/ 














/ 




, / 


/ 


/ 


/ 




^ 




/ 


/ 


/ 


y 


/ 




/ 


/ 




A 


/ 


/ 


V 


V 


/ 






V 









































































































Tubercular meningitis. Male, 11 months old. 



The history at that time was that he had always been well and strong, except that he 
had had bronchitis in December and that the cough had returned at intervals. He had at 
that time six teeth. There was a tubercular history on the mother's side of the family. 
He had remained well and thriving until you saw him here, when he seemed feverish and 
rather dull ; there were anorexia and insomnia, and he was said to have become tired easily. 
The temperature had been rather high, 39.4° to 40° C. (103° to 104° F.), the pulse quick and 
regular, and the respirations rapid but regular. Nothing abnormal was found on physical 
examination, and, as the gums were swollen and hot, no diagnosis was given, and a guarded 



ORGANIC NERVOUS DISEASES. 625 

prognosis. He remained in this condition until March 17, when I noticed an apparent 
approach to Cheyne-Stokes respiration and a little retraction of the head. There was no 
photophobia, and the pupils were equal and reacted well. There were no vomiting and 
no tache cerebrate. The bowels were regular ; the tendon reflexes were exaggerated, but 
nothiiig else abnormal was found in the lungs, heart, or abdomen. On the following day 
he was found to have ptosis of the left eyelid. The fontanelle was depressed ; the abdo- 
men was distended. He gradually grew worse, and died on March 22, about ten days after 
pronounced symptoms of any disease had begun. 

Here is the chart (Chart 23, page 624) of his temperature and pulse. The respirations 
during the whole course of the disease varied from 80 to 100. 

This next case^ which I saw in consultation with Dr. Broderick, of 
South Boston, represents tubercular meningitis as it appears in the second 
year of life. You will notice how at this period it is rapidly approaching 
the characteristic symptoms of the disease which are met with from the 
third to the seventh or eighth year, and even later. 

A boy (Case 277), fifteen months old, had always been healthy. His mother was 
healthy, but his father had died of tuberculosis. He had twelve teeth, and was cutting one 
of his canine teeth, the gum over which was swollen and tender. He had always had a 
tendency to constipation. He was perfectly well until he was fourteen and a half months 
old, when he did not have a movement of the bowels for a week. He became fretful, and 
towards the end of the week his respiration was noticed to be of the Cheyne-Stokes type. 
His pulse varied from 80 to 150 and was regular. The temperature in his axilla varied 
from 37.4° to 38.1° C. (99.6° to 100.6° F.). At times there was rigidity of the hands, but 
there were no regular convulsions. He vomited at the beginning of the attack, but not 
afterwards. 

When I saw him, in the second week of the disease, his eyes were rolling from side to 
side and there was much Meibomian secretion. He was unconscious, but he was said in the 
night to have put his hand to his head and to have cried out as though he were in pain. 
There was some stiffness of the neck and back. There was a rather marked tache cerehrale^ 
and there was decided depression of the abdomen. The pupils were equally dilated and 
responded to light. There was considerable emaciation. 

During the following week at one time for a few seconds he had decided opisthotonos. 
He gradually sank and died. The duration of the disease was four weeks. 



40 



626 PEDIATRICS. 



BRAIN.— (Continued.) 
Thrombosis op the Cerebral Sinuses. — Hydrocephalus. 

THROMBOSIS OF THE CEREBRAL SINUSES.— Thrombosis of 
the cerebral sinuses is a very uncommon condition. The disease is more 
frequent in infancy and early childhood than in adult life. It is caused by 
the formation of an ante-mortem clot in one of the sinuses of the brain. 
As a primary condition it is exceedingly rare. It is usually secondary to 
some condition which has produced a deep impression upon the child^s 
vitality, such as profound ansemia, exhausting diarrhoea, or a collection of 
pus in any part of the body, but especially about the scalp, as in erysipelas. 
A purulent otorrhoea is perhaps the most common etiological factor. It is 
not necessary here to do more than refer to the traumatic cases of this disease, 
such as involve the ear and the scalp, as in fracture, or where the disease is 
caused by compression, as from a cerebral tumor. The pathology of the 
secondary cases includes the lesions of the different processes which have 
caused the thrombosis. That of the idiopathic or undetermined cases is 
well represented in these specimens which I am about to show you (Case 
279). The thrombosis may take place in any of the cerebral sinuses, and at 
times may occur in the course of a meningitis. When the thrombus is 
formed, the venous branches behind the obstruction become distended me- 
chanically, and thus give rise to capillary hemorrhage and softening of 
the floor of the ventricles. When the thrombosis has taken place in the 
neighborhood of some inflammatory focus, such as a purulent otitis media, 
pyaemia may result. 

So few cases have been reported where the diagnosis has been established 
by a post-mortem examination, that the clinical description of the disease 
must necessarily be very limited. The symptoms which existed in cases 
where this condition has been found on post-mortem examination are not 
such as to suflice for making a differential diagnosis during life between 
this and other intra-cranial conditions, such as occur in profound anaemia. 
Where, however, convulsions occur in an atrophic child, especially if there 
has been chronic trouble in the ear, we can suspect the presence of this con- 
dition after carefully differentiating all other causes. Cases of thrombosis 
of the lateral sinus may be suspected where symptoms of a severe purulent 
aifection follow a suppurative otitis, with involvement of the mastoid cells, 
and where there is a tenderness over the external jugular vein. 

The prognosis in this disease is usually fatal, except where it occurs in 
the lateral sinus and can be relieved by operation. Pitt reports the recovery 



OKGANIC NEEYOUS DISEASES. 627 

of a boy (Case 278) ten years old who had chronic otorrhoea, followed by 
acute symptoms of fever and aural tenderness. Following these symptoms, 
a week later, he had a rigor, and optic neuritis was developed on the right 
side. Exploration of the lateral sinus disclosed a clot, which was removed, 
and the boy recovered. 

I will now show you the results of a post-moitem examination which 
has been made by Dr. Whitney on an infant nine weeks old. 

This infant (Case 279) was seen by you with me in the wards of the Infants' Hospital 
two weeks ago, and at that time it was apparently well and strong. You saw it two days 
ago unconscious and having an irregular type of convulsions. 

When first seen by me, January 16, it was, so far as I could judge, strong and healthy, 
weighing 4805 grammes (about 10 J pounds), which at six weeks is decidedly a greater 
weight than the average. The average weight of the male infant at birth, as I then told 
you, is about 3250 grammes (about 7 pounds 2f ounces.) Allowing for a daily gain of 30 
grammes (1 ounce), the weight of an infant six weeks old should be 4510 grammes (about 
9 pounds 14 ounces), so that this infant weighed 295 grammes (about 9| ounces) more than 
the average infant of the same age. 

On entering the hospital it took its food well, had two or three apparently well-digested 
dejections daily, slept well, and seemed to thrive for the following week. No one would 
have known from its outward appearance that anything was the matter with it if it had not 
been carefully weighed, when it was found that it was losing. The following is the record 
of its weight from January 16 until its death, January 30 (Table 102) : 

TABLE 102. 

Date. Weight. Gain or Loss. 

Gramines, Grammes. 

January 16 ... 4805 

January 18 4655 Loss, 150 

January 20 4630 Loss, 25 

January 21 4595 Loss, 35 

January 22 . 4610 Gain, 15 

January 23 4590 Loss, 20 

January 24 4425 Loss, 65 

January 25 4420 Loss, 5 

January 26 4420 Loss, 

January 27, 8.30 a.m 4110 Loss, 310 

January 27, 6 p.m 3995 Loss, 115 

January 27, 7 p.m 3925 Loss, 70 

January 28 3945 Gain, 20 

January 29 3965 Gain, 20 

January 30 3735 Loss, 230 

On January 23 the loss of weight was very evident, and various changes were made in 
the infant's food, but with no good result, as he vomited and had thin watery discharges 
from the bowels. 

On January 28 he seemed weak and did not look well. A wet-nurse was procured for 
him, but her milk did not agree with him, and in fact he became much exhausted when 
trying to nurse. 

At 7 P.M. he was examined by Dr. Haven and myself, with the following result. His 
temperature was 38° C. (100.4° F.). His respirations were 35, and were natural. The 
pupils were normal and reacted to light. The fontanelle was very slightly depressed. The 
child did not seem to be in pain. Nothing abnormal was detected in the thorax, abdomen, 
or throat. 

On January 28 he vomited considerably during the day, and had a natural yellow 



628 PEDIATRICS. 

fsecal dejection, but he would not take Ms food. His pupils were contracted equally, and 
he had rhythmical contractions of the arms and legs, first on one side and then on the 
other. Accompanying these movements was opisthotonos. The head and eyes were drawn 
to the right. There was no rigidity or paralysis of the legs or arms. The fontanelle was 
not depressed. There were rapid contractions of the eyelids, first on one side and then on 
the other. 

On January 30 he had six rather watery faecal movements. The muscular contrac- 
tions ceased, but the opisthotonos continued until just before his death, which occurred at 
6.30 P.M. 

You see that the face is thin and pinched ; the body is small and somewhat emaciated ; 
there is slight rigor mortis ; the calvaria is removed without difficulty. On close exami- 
nation, nothing abnormal is noticed on the external surface of the dura mater. In the 
straight sinus and in the portion of the superior longitudinal sinus immediately adjoining 
this is a formed red clot, slightly decolorized in parts, but easily removed from the vessels, 
and evidently ante-mortem. The other sinuses contain a little loosely-clotted blood. The 
surface of the brain is moist, and the spaces between the convolutions are slightly opaque 
and cloudy from the presence of a serous fluid. The blood-vessels of the pia mater are 
injected. Upon opening the lateral ventricles and turning back the fornix the floor of the 
ventricles is seen to be covered with numerous thromboses of the blood-vessels and its sur- 
face to be universally reddened. The ependyma is roughened and infiltrated, and there is 
a bloody serous fluid in the cavity of the ventricles. The veins of the choroid plexus are 
filled with dark clotted blood which is directly continuous with that found in the straight 
sinus. The substance of the brain is moist. The spinal cord presents a moderate injection 
of the vessels of the pia mater. Both sides of the heart contain dark loose clots, and the 
heart itself is normal. The lungs are slightly oedematous. The other organs present 
nothing abnormal. 

As a summary of the case we have an infant nine weeks old, apparently strong and 
well up to January 16, when it began to lose in weight. By January 23 it had lost over 
200 grammes (6f ounces) without showing any other symptom of disease. By January 
27 it had lost 480 grammes (16 ounces). Two days later it was attacked with convulsions 
and died. The autopsy showed nothing abnormal except a capillary hemorrhage into the 
ventricles caused by a thrombosis of the straight cerebral sinus. 

The pathological diagnosis in this case is that of a sinus-thrombosis of undetermined 
origin, a condition which is exceedingly rare, and instances of which established by autopsy 
have seldom been reported. 

Tirard reports the case of a boy four years of age, which is of consider- 
able interest and value as representing secondary sinus-thrombosis. 

The child (Case 280) was well until he had measles ; from that time he lost in weight 
and strength. Just previous to coming under medical observation he had several severe 
convulsions, had been stupid, and had not spoken to any one. 

On examination he was found to be emaciated and to have a coated tongue ; his teeth 
were covered with sordes ; his bowels were constipated. He was semi-conscious occasionally, 
and had slight convulsions, in which the left arm was generally aflected. There was no 
drawing of the face ; the pupils were equal ; there was no strabismus, no retraction of 
the head, no tenderness of the spine. The patellar and plantar reflexes were present, 
equal and normal. There was no anaesthesia nor analgesia ; a tache cerebrale could be 
obtained. There was a purulent discharge from the left ear. The urine contained a trace 
of albumin. 

In the next two days there were several convulsions and a rise of temperature, followed 
by a brief return of consciousness. Examination of the chest showed dulness and crepita- 
tion over the base of the left lung. 

A week later the mouth was noticed to be drawn to the left. Trembling of the hand, 
resembling the oscillations of paralysis rather than the movements of chorea, then appeared. 
"When the child was lying undisturbed these tremulous motions ceased, but they became 



ORGANIC NERVOUS DISEASES. 629 

exaggerated when the limb was raised, and were then accompanied by tremulous move- 
ments of the face. Death occurred two weeks later. 

The post-mortem examination showed thrombosis of the cerebral sinuses. There were 
numerous small abscesses in the lungs, apparently from infarctions. The longitudinal and 
lateral sinuses contained well-marked decolorized thrombi. In the latter they were soft ; in 
the former, firm. There was pus in the left tympanum and in the mastoid sinuses. There 
was no perforation of the membrana tympani, and no necrosis of the petrous bone. 

HYDROCEPHALUS. — I shall next describe a disease of the brain 
which is characterized primarily by an exudation of fluid into the mem- 
branes of the brain or one of its cavities. 

For lack of a better name, we designate the disease by the term repre- 
senting the most prominent pathological condition, — namely, hydrocephalus 
(water in the head). 

In order that you may clearly understand what I am about to say, I 
shall ask you to refer again to this diagram (Diagram 8, page 594), show- 
ing a section of the skull, the cerebral membranes, and the brain. 

The general shape and circumference of the head in infancy and child- 
hood vary in the individual to a considerable degree. This has already 
been spoken of in a previous lecture (Division II., Lecture III., page 61), 
and is merely referred to here for the purpose of illustration, because the 
skull and its contents have so close a connection in the mind of the student. 

On the other hand, when these variations in size pass a certain limit, or 
are combined with certain nervous phenomena, they have a distinct patho- 
logical significance. 

Hydrocephalus may be (1) external or (2) internal. 

(1) The external variety consists in a transudation into the subarachnoid 
space and the meshes of the pia, represented in this diagram by Sub. A. S. 
(Diagram 8, page 594). This external variety is very rare, and may be 
either congenital or acquired. 

(2) The internal and common variety of hydrocephalus consists in a 
transudation into the cerebral ventricles. It may be congenital (intra- 
uterine) or acquired (extra-uterine), and its cause may be mechanical or 
inflammatory. Acquired internal hydrocephalus may be acute or chronic. 
The acute form of the disease usually occurs as a symptom or a cause of 
symptoms in the course of such diseases as rhachitis, cardiac and renal 
disease, pertussis, and meningitis, and in various other diseases. It may be 
also apparently idiopathic. The chronic form of acquired internal hydro- 
cephalus resembles so closely congenital internal hydrocephalus that we 
can consider them together, and, so far as the name of the disease is con- 
cerned, the term hydrocephalus would be restricted best to (1) congenital 
internal hydrocephalus and (2) chronic acquired internal hydrocephalus. 
In other words, there exists pathologically a certain class of efliisions into 
the ventricles for which no cause is apparent. When these efliisions reach 
a certain amount the resulting symptoms are quite typical of what is called 
hydrocephaUis, and clinically the term has therefore been confined to cases 
of this class. 



630 PEDIATRICS. 

This table (Table 103) will aid you in understanding the classification 
which I have just given you : 

TABLE 103. 

Hydrocephalus. 



External Internal 

(into subaraclinoid space). (into ventricles). 



Congenital. Acquired. Congenital. Acquired. 



r 



Mechanical. Inflammatory. Mechanical, Inflammatory. 

I 



Acute. Chronic. Acute. Chronic. 

In addition to the effusion which takes place in either external or 
internal hydrocephalus, there may be a combination of both, as there is a 
communication between the fourth ventricle and the subarachnoid space by 
means of the foramen of Magendie. 

(1) External Hydrocephalus. — External hydrocephalus may occur 
as a congenital disease, but this occurrence is so rare that little can be 
said concerning it. I have met, however, with one instance of a somewhat 
analogous condition which I saw in consultation with Dr. Boughton, of 
Jamaica Plain, from whom I received the complete notes of the case. It 
seems very likely that this was a case of congenital cyst. 

A female infant (Case 281) was born of a healthy primipara, the delivery being assisted 
by forceps. The infant appeared to be strong and vigorous and was not cyanotic. Its head 
was natural in shape and size, and there was no evidence of undue or prolonged instrumental 
pressure. Its weight was 3632 grammes (8 pounds). Nothing unnatural was noticed 
about the infant for several days, except that it did not nurse well. At these times it 
would cry and refuse to nurse. Its mother had a sufficient supply of good breast-milk. 

When it was five days old it looked rather pale and thin, and on the sixth day, when 
the nurse was giving it its bath, she noticed that its right arm twitched convulsively several 
times. This twitching increased in frequency and force and was accompanied by a marked 
change in the infant's face. It became very pale and was cyanotic around the lips and 
eyes. At times it would cry out sharply both during the convulsive twitchings and in the 
intervals. Sometimes it would pass into a state of semi-collapse and would be cold and 
very pale. At this time also it would jerk its right arm convulsively at the rate of 75 
times a minute. These spasmodic movements seemed to be confined to the right arm. 
There was no muscular contraction elsewhere, no frothing at the mouth, unconsciousness, 
or other evidence of general convulsions. Sometimes the respirations would be very faint 
and scarcely perceptible. The pulse would be weak, about 90 per minute, and then the 
infant would suddenly begin to breathe with great rapidity and the pulse would increase 
to 120. The area of cardiac dulness was not increased. There was a moderately loud, 
double cardiac souffle, most marked at the second left intercostal space, but heard all over 
the upper part of the sternum. In the right back, at the angle of the scapula, there was a 
patch of dulness about 2.5 cm. (1 inch) in diameter, but there were no rales over this area 
of dulness. The expansion of the lungs was irregular. The temperature was slightly 
subnormal. 

The infant was wrapped in cotton-wool and surrounded with heaters. Brandy and 
aromatic spirit of ammonia were given in alternate doses of 0.3 c.c. (5 minims). 

On the eighth day it was reported that the convulsive twitchings had continued, and 



ORGANIC NERVOUS DISEASES. 



631 



that there had been twenty-five spasmodic attacks within the previous twenty-four hours. 
The infant was still in a state of collapse, the pulse and respirations were very weak and 
irregular, and sometimes it w^ould actually stop breathing for a minute. It was semi- 
unconscious. Its pupils were dilated. The abnormal signs found in the chest were 
unchanged. 

On the ninth day the convulsive movements had ceased, but the child was still in a 
state of collapse and remained perfectly dormant and passive. 

On the tenth day the convulsive movements began again, and at times the infant ap- 
peared lifeless. On this day oxygen was administered for five minutes every hour. The 
brandy was increased to 0.72 c.c. (12 minims). The infant had been too weak to nurse for 
several days, and the mother's milk was given to it by means of a dropper. 

On the eleventh day the oxygen was given for ten minutes at a time every hour, and 
brandy whenever signs of unconsciousness appeared. 

During the next few days the infant began to show signs of improvement. The 
cardiac souffle became less distinct. The atelectasis of the lung remained unchanged. 
During the time when the infant was so ill there was no disturbance of the bowels or 
kidneys. 

On the seventeenth day modified milk was substituted for the breast-milk. From this 
day the infant rapidly improved. The cardiac soufiie lasted for six weeks, and the atelec- 
tasis gradually disappeared, the last signs of it being a little diminished respiration in the 
right back. The oxygen was continued in small doses for six weeks ; 8400 litres (2000 
gallons) were used. Of this, of course, a certain quantity was not inhaled, but escaped, as 
the funnel was held rather lightly over the infant's mouth. The infant had become con- 
siderably emaciated, but when it was four weeks old it had greatly improved, and, although 
weighing only 3405 grammes (7 J pounds), looked fairly well. 

When the infant was a little more than four weeks old the head was perfectly normal in 
shape and size. The fontanelle could be seen pulsating naturally and was normal in shape 
and size. 

I have here a tracing (Case 281, I.) from a photograph which was taken of the infant 
at this time. 

On the following day the head was found to be noticeably altered in shape, and this 
second tracing (Case 281, II.) was made from a photograph which was taken when the 



Case 279. 



II. 





Congenital external hydrocephalus or congenital cyst. 



child was somewhat older. The rounded, full forehead had disappeared, and, instead of look- 
ing natural, the child had the appearance of an idiot. The report of the nurse was that 
while it was being dressed in the morning it had vomited some fluid like water, and that 
the head had assumed this shape within the course of a few minutes. Both segments of the 
frontal and the parietal bones had flattened, and apparently had settled or collapsed. The 
anterior fontanelle had entirely closed, and the frontal suture could not be felt. A line 
drawn from the vertex to the root of the nose was entirely straight, instead of showing the 
normal curve. The width of the forehead was also diminished. The entire frontal bone 
was so flat that it lay upon a lower plane than the parietal bones, — perhaps 1 cm. (f inch) 



632 PEDIATKICS. 

below them. The edge of the parietal bones could be plainly felt along the coronal suture, 
and the little finger could almost be laid upon the frontal bone in the depression. The pos- 
terior part of the head appeared to be unchanged in shape, but the skull, instead of being 
round and normal, had become microcephalic. The infant in other respects seemed to be 
in good health, took her milk naturally, and no new pathological signs were discovered. 

When the infant was six months old the circumference of the head was 35 cm. (13^ 
inches). When it was fourteen months old the head measured 36.5 cm. (14^ inches). From 
the occiput to the root of the nose it measured 19 cm. (7^ inches), from the occiput to the 
chin it measured 37.5 cm. (14| inches). There was a complete closure of the sutures and of 
the fontanelles. The infant weighed 7718 grammes (17 pounds), and was 71 cm. (2 feet 4 
inches) in height. There were but few signs of intelligence. It recognized no one. It 
was as contented with strangers as with its mother. It was partially blind, and did not 
notice objects or persons, although it appeared to notice light slightly. 

An examination of the eyes by Dr. Dixon showed that externally they appeared to be 
normal. The pupils were smaller than natural, and responded slowly to changes of light. 
Light was noticed somewhat, but the infant would not follow it, and it was found that it 
could see better from the side. The macula and disk showed no indications of inflamma- 
tion or exudation. There was a very slight degree of astigmatism. 

The infant could neither talk nor walk. It had a vacant manner, cried hysterically, 
and it sometimes required an effort to stop the crying. Otherwise it was pretty well de- 
veloped. It had one tooth. The hearing was defective. There was at times digestive 
disturbance. 

For the past three or four months there had been a return of the spasmodic twitchinga 
of the right arm similar to those which occurred during the acute attack of atelectasis and 
cardiac disturbance. During one of its digestive attacks the infant apparently had an 
epileptiform convulsion. 

A rapid loss of cerebro-spinal fluid is not unknown, but in these cases 
there has usually been a history of injury. Where we do not have a his- 
tory of injury we almost always find that there is a considerable amount of 
fluid coming from the nose, ears, or elsewhere. According to Dr. Bullard, 
in this case the infant seems to have first swallowed the fluid and then 
vomited it. The means of exit of the fluid from the skull was probably 
through some congenital defect at the base of the skull. 

It is known that in a great many children who have hydrocephalus and 
similar conditions the atrophy or non- development of the brain may not 
show any symptoms until they are a year or more old. The parents do 
not notice anything, and the physician is unable to, because he has not 
the opportunity for suflicient observation. To determine imbecility in very 
young children, unless it is marked, is a very difficult matter, and even when 
the child is brought to the physician to determine this condition it is often im- 
possible to decide before the second year of life, so that the fact that nothing 
was noticed in this especial child's (Case 281) mental condition previous to 
the collapse of the skull would afford no proof that there was not or had 
not been previously hydrocephalus, and perhaps atrophy or non-formation 
of a portion of the brain. It also would not be necessary in the case of 
congenital atrophy or non-development of the brain to have any motor 
paralysis or sensory disturbance, or convulsive phenomena of any kind 
whatever, although these symptoms usually occur under these conditions. 
In these cases we often find optic atrophy, but in a number of such cases no 



ORGAXIC NERVOUS DISEASES. 633 

optic atrophy can be found by means of the ophthalmoscope. In a consid- 
erable proportion of cases of this kind there is a diminution of vision which 
is not explained by anything that the oculists tell us. 

Henoch mentions a case of hydrocephalus in which the fluid drained 
through the nose to the amount of 100 to 200 c.c. (3J to 6f ounces) a day 
for quite a long time, so that the hydrocephalus was reduced considerably. 

The acquired form of external hydrocephalus is exceedingly rare, and is 
usually found in connection with cerebral atrophy (hydrocephalus ex vacuo). 
There are certain cases which can for the present be classed under this head- 
ing until our knowledge derived from post-mortem examinations becomes 
more precise. These cases are so rare that it is impossible at present to for- 
mulate in detail their symptomatology and diagnosis. I have met with a few 
cases, however, which in their symptoms were so significant of a rapid devel- 
opment, with its speedily fatal issue, of an external hydrocephalus, that the 
diagnosis of hydrocephalus by the elimination of other possible causes has 
seemed to me rational, and has been supported by the post-mortem exami- 
nation. The symptoms may develop, according to my experience, in young 
infants who either have been fairly well or have been atrophic. Phys- 
ical examination in these cases has revealed nothing abnormal about the 
head or any of the organs, such as the heart. The infant, after a short 
period of indefinite symptoms, at times lasting only a few minutes, and 
represented by nervous twitching, perhaps a convulsion and rapid collapse, 
suddenly dies. I have met with three cases in my personal practice. Two 
were, after minute post-mortem examination by Dr. William F. Whitney, 
found to represent as their only pathological lesion external hydrocephalus 
with oedema of the cerebral substance. The third case showed this condition 
merely as a symptom of pernicious anaemia, and I have spoken of it in a 
previous lecture. 

One of these cases was an infant (Case 282), ten months old, of healthy parentage, and 
always perfectly well, except that for two weeks before its death it had cried more than 
usual and was somewhat irritable. Five days before its death it was somewhat languid, 
but took its food well, and when I examined it the night before its death nothing abnor- 
mal was found. On the following morning it had a few convulsive movements and died 
suddenly. 

On post-mortem examination nothing abnormal was found, except that a large amount 
of cerebro-spinal fluid escaped from the cranium as soon as the skull and parietal dura 
mater were removed. There was also a general cedematous condition of the brain. 

The other case was a female infant (Case 283), seven and one-half months old, which 
had been sutfering from malnutrition for several months and was very weak and puny. 
On the day of its death I examined it carefully, and, with the exception of an atrophied 
condition of the muscles and a weak action of the heart, nothing abnormal was discovered. 
Within an hour after I had seen the infant it had a few convulsive attacks and died sud- 
denly. 

The autopsy, made twenty-four hours after death, showed nothing abnormal externally. 
Eigor mortis was present. There was great pallor of all the organs. The skull was normal 
in development, and the fontanelle was normal. There was cerebro-spinal fluid in excess. 
The brain-substance was very moist and pale, but otherwise nothing abnormal was noticed 
in the brain or meninges. The heart was of normal size, and its cavities and valves were 



634 PEDIATRICS. 

normal. The ductus arteriosus and Eustachian valve were closed. The muscular substance 
on the right side of the heart was pale and opaque, while that of the papillary muscles on 
the left side was pale but not opaque. Microscopic examination showed the muscular sub- 
stance to be filled with minute, highly refracting granules, which in part dissolved on 
the addition of acetic acid, but were left undissolved in some places, where the structure 
of the fibre was destroyed. On the left side of the heart granules were present which 
could be wholly dissolved in the acetic acid. There was fatty degeneration more or less 
marked of the cardiac muscles and also of the diaphragm, the fibres of which showed 
numerous granules, which dissolved in acetic acid in about one fibre to fifty. The kidneys 
were pale, but otherwise nothing abnormal, either microscopically or macroscopically, was 
found. The supra-renal capsules were normal. The liver was of normal size, and on section 
its surface was found to be dry, yellowish, and opaque. Microscopic examination showed 
that the liver-cells were filled with fat-drops of varying size, especially numerous in the 
cells of the periphery of the lobule. The cells themselves had a sharp outline and a well- 
defined nucleus. The pancreas was normal. The stomach was normal in size, and con- 
tained considerable milk, with but few curds. Nothing abnormal was detected in it by 
microscopic examination. The small intestine contained a very little soft, yellowish material. 
The large intestine contained a small amount of yellowish, soft faeces. No enlargement of 
Peyer's patches or of the solitary follicles was found. The mucous coat was normal. 

(2) Internal Hydrocephalus. — Internal hydrocephalus may be 
congenital or acquired. The earlier the hydrocephalic condition begins, the 
larger will the cranium become. We therefore find the very large heads, as 
a rule, to be of the congenital variety. The head is at times of such a size 
as to cause difficulty in the delivery, or the fluid may collect very rapidly 
after birth, and the head soon assumes the characteristic appearance of 
hydrocephalus. 

This skull of a child three years old (Fig. 92) is an exaggerated type 
of the congenital internal hydrocephalic head. 

This other skull of a child, also three years old (Fig. 93), which I 
place beside the hydrocephalic skull, represents a normal head of the same 
age. 

The face in these cases of hydrocephalus remains about the same size as 
it would be normally, but usually looks much smaller from the dispropor- 
tionate size of the head, which rests upon it from above like a globe. 

Congenital Internal Hydrocephalus. — The cause of congenital in- 
ternal hydrocephalus is somewhat obscure. In some cases it is of inflam- 
matory origin, in others no evidence of inflammation can be found. 

Pathology. — The anatomical appearance of the brain itself, as a rule, 
corresponds with and may be accepted as the result of pressure by an intra- 
ventricular fluid. This brain (Fig. 94, page 635) was taken from a child 
who died of congenital internal hydrocephalus, and well exemplifies the 
pathology of the disease. 

You see that the convolutions are flattened and that the walls of the 
ventricles are much thinned by the intra- ventricular pressure, while the ven- 
tricles themselves are much dilated. In some parts the cortex is less than 1 
cm. (I inch) in thickness. The amount of fluid in these cases varies from a 
few cubic centimetres to three or four litres. The fluid has a specific gravity 
of about 1004. 




T.^-.^ 




ORGANIC Is-ERVOUS DISEASES. 635 

Symptoms. — The symptoms of congenital internal hydrocephalus are 
essentially those caused by pressure. We naturally, therefore, find the 
fontanelles bulging and fluctuating, and the bones thin and forced out of 
position. As you see in this skull (Fig. 92), the temporal and parietal 
bones diverge as they extend upward, while in the normal skull they 
ascend almost perpendicularly. If the disease has existed for some time, 
the upper wall of the orbit becomes flat and the eyeballs protrude. The 

Fig. 94. 




Hydrocephalic brain. Warren Museum. Harvard University. 

intra-cerebral pressure often produces a strong collateral circulation in the 
scalp and the forehead, where the vessels appear like tortuous blue cords. 
Functional disturbances are numerous, and vary in almost every case. As 
a rule, the children are idiotic, but at times, even in marked hydrocephalus, 
we find the mental condition normal, even when paralysis is present. A 
notable instance of this fact is presented by this little girl whom I have had 
brought here to-day to show you. 

This child (Case 284, page 636) is five years old. 

You see that, although she has completely lost the power of using her legs, and has 
a large head and distended, hulging fontanelle, yet she is bright and intelligent. She 
was nursed by her mother for over a year, and cut her first tooth when she was six months 
old. She was always well and strong, but high-tempered. She has never had any disease. 
When she was five months old she fell from her crib and struck her head, but it did not 
seem to hurt her especially. Her head was always noticed to be of a peculiar shape. 
When she was eight months old she fell out of a chair and was stunned, but was not other- 
wise hurt. She has had convulsions from time to time, but her mind has always been 
brio-ht. She was unable to hold up her head until she was three years old, and has always 
complained of more or less frontal headache. Her appetite has always been excessive, and 



636 PEDIATRICS. 

her taste for food somewhat peculiar. She has gradually grown stronger, and is beginning 
to attempt to walk. She sleeps well, and her bowels are regular. Her head measures 57 
cm. (22^ inches). 

Case 284. 




Congenital internal hydroceplialus. Female, 5 years old. 

As the various cerebral centres become affected by pressure, we notice 
that symptoms arise corresponding to the parts of the brain which are 
affected. Among these symptoms are nystagmus and, less frequently, stra- 
bismus. The pupils at first are usually moderately dilated. Later they 
become fixed, and sensibility to light is lost. The hearing lasts for a long 
time. The ability to walk is interfered with. Partial or general convulsions, 
paralysis (usually paraplegic), and contractures may occur. Pain in the 
head is often complained of, but, as a rule, is not so severe as in meningitis. 
There is difficulty in keeping the head erect, as it is so heavy. The diges- 
tion is often good, and the appetite usually extreme. The respiration is 
normal from adaptation. The pulse is usually not retarded. The tempera- 
ture, as a rule, is normal. The adipose tissue is often abnormally increased. 

Diagnosis. — As congenital internal hydrocephalus is almost invariably 
attended by enlargement of the head and separation of the sutures, the 
diagnosis is not especially difficult, and is determined by comparing the 
measurements of the head with those of a normal head of the same age. 
I have described the measurements of a normal head in a previous lecture 
(Lecture III., page 61). In addition to the enlargement of the head, the 
symptoms of direct intra-cephalic pressure make the diagnosis very simple. 

Prognosis. — These congenital cases, as a rule, die before childhood has 
been reached, but they have been known to live to middle age. Death usually 
occurs from some intercurrent affection. Complete recovery is very rare. 

Treatment. — The treatment of congenital internal hydrocephalus has 
been varied, but without marked success. When the effusion is not large 
and is not increasing, moderate pressure with a rubber bandage seems to 
have a favorable result. Where the disease is apparently not in an active 
state and is characterized by a very slight increase of fluid, aspiration 



ORGANIC NERVOUS DISEASES. 637 

through the anterior fontanelle of a small quantity of fluid at a time has 
been of temporary benefit. The point of aspiration should be 2 to 3 cm. 
(f inch to IJ inches) from the median line, so as to avoid puncturing the lon- 
gitudinal sinus. In this way the condition of the patient is often rendered 
more satisfactory. 

An operation for chronic hydrocephalus presents no technical difficulties. 
Of course only certain cases are suitable for operation. Moderate effusions 
should be let alone, also those cases where a rudimentary development of 
the brain is suspected. Cases where an operation is especially indicated 
are comparatively both physically and mentally well developed up to the 
time when the enlargement of the cranium began. Such children should 
show the symptoms of direct intra-cranial pressure. They are evidently be- 
coming weak-minded or idiotic. They do not learn to talk, or they quickly 
forget what they have learned. They may also have become totally blind. 
The power of walking is interfered wdth. Contractions and partial and 
general spasms are of ordinary occurrence. Unless the pressure is speedily 
removed, atrophy of the brain results, and if they live they remain idiots 
for life. Such cases as these you can best refer to those who are skilled 
in neurology and surgery. 

I have in my wards to-day a number of cases of congenital internal 
hydrocephalus to show to you, which are of considerable interest in view 
of what I have just told you. 

Of these illustrative cases I will first show you this infant (Case 285), two years old, 
which is sitting in its mother's lap. 

The special point of interest in this case is that the circumference of the mother's head 
and that of the child's head are almost identical, 52 cm. (20^ inches). You will notice the 
overhanging brow and deep-set eyes, the globe-shaped head and open bulging fontanelles, 
the small face and oblique parietal bones of the infant's head in comparison with the nor- 
mal, round shape of the mother's head. 

The history, so far as the mother is concerned, is negative. She has had no miscar- 
riages. The infant was born at term, and cut its first tooth when it was six months old. 
It now has sixteen teeth. It has had no convulsions. It has for some time supported its 
head alone and sits alone, but has never attempted to walk. The intelligence seems normal. 
It is apt to sleep with its eyelids partly open. Its digestion is good, and its appetite is 
very good. The bowels are rather relaxed. On examining the head you will see that it is 
abnormally large. From the root of the nose to the occipital prominence it measures 32 
cm. (12J inches). From the base of one mastoid to that of the other it measures 33.5 cm. 
(13^ inches). The position and movements of the eyes are normal. You will notice, on 
looking at the head from above, that it is triangular in shape, with the base of the triangle 
at the occiput. The anterior fontanelle you see is widely open, and is about 4 cm. (1^ 
inches) in width and length. The protruding overhanging forehead makes the face look 
small. The epiphyses are not enlarged. Examination of the lungs, heart, and spleen 
shows nothing abnormal. The child weighs 10,442 grammes (23 pounds). 

In this next bed is a boy (Case 286, page 638), three and a half years old, whose head 
is typical of congenital internal hydrocephalus. The circumference of the head is 57 cm. 
(22^ inches). 

There is no history of disease in the parents, and the mother has had no miscarriages. 
The child's head has always been large since birth. He has never had any convulsions. 
He cut two teeth when he was four months old, and when he was a year old he had ten 
teeth. He walked when he was fourteen months old, but his legs never seemed strong. 



638 



PEDIATRICS. 



He has never had any paralysis, but he gets tired easily. Nine months ago he fell down one 
step, and half an hour later began to vomit and was somnolent. During the following 

Case 286. 





Congenital internal hydrocephalus. Male, 33^ years old. 

two days the vomiting and somnolence continued, but he was never unconscious. His heaa 
then began to increase in size, so that his mother had to buy him larger hats. Before the 
accident he had always held his head up. He talked when he was fifteen months old, and 



Case 287. 




Congenital internal hydrocephalus. 

seemed to be an unusually bright child. He holds his eyelids partly open when he is asleep, 
and he has lately had strabismus of one of his eyes when he looks steadily at an object. The 
head is markedly enlarged, with a broad, protruding fontanelle, and is rather flattened at 



ORGANIC NERVOUS DISEASES. 



639 



the vertex. The superficial veins of the head are prominent. The face, as in the other 
child (Case 285), is small. The movements of the eyes are normal. From the tip of one 
mastoid process to that of the other is 41.5 cm, (16^ inches). From the hase of the nose to 
the occipital protuberance is also 41.5 cm. (16^ inches). The anterior fontanelle is widely 
open and is 2.5 cm. (1 inch) long and 2.5 cm. (1 inch) wide. An examination of the heart, 
lungs, liver, and spleen shows that they are normal. The abdomen is prominent. The 
radial epiphyses are enlarged, and there is a slight outward bowing of each tibia. The 
spine is straight. The patellar reflexes are not increased, and there is no ankle-clonus. 
The urine is pale, thin, and clear, and contains no albumin. An examination of the eyes 
by Dr. Davis shows no marked diminution of vision in either eye. They are hyperme- 
tropic, and there is a convergent strabismus, probably accommodative. The optic disks are 
rather wider than usual, and their vessels diminished in size. There are no other signs of 
optic atrophy. There is no dilatation of the retinal veins or swelling of the disks. The 
examination, therefore, shows that, with the exception of an early stage of atrophy of the 
optic nerve from pressure, the fundus oculi is negative. 

In this case a chronic congenital effusion was apparently actively increased by a blow 
on the head. 

This little boy (Case 287, page 638), a patient of Dr. Haven's, is an interesting case of 
hydrocephalus, with its accompanying disturbance of the motor function of the legs, and 
also mental impairment. He is a characteristic picture of the disease. He cannot walk, 



Case 288. 





Internal hydrocephalus (probably congenital). Female, 6 years old. 



but is able to sit in a chair. His legs are atrophic, his abdomen is distended, and he is 
somewhat emaciated. His head, as you see, is decidedly enlarged, and he is mentally weak. 
His appetite is excessive. He is very fretful and peevish. 

Cases of this kind are very apt to live for only a few years, and are especially liable to 
die if they are attacked by any intercurrent disease, such as pertussis. 

This little girl (Case 288) is six years old. 



640 PEDIATRICS. 

She is said to have been normally developed and healthy at birth, but was unable to 
hold her head up until she was two years old. She has never walked. 

You notice on looking at the head, both in front and in profile, that it is abnormally 
large. It measures 65 cm. (26 inches). The movements of the hands and arms are normal. 
She cannot stand unless she is supported, and there is a spastic condition of the legs, with an 
exaggeration of the knee-jerks. She articulates well. 

She represents a case of partial recovery from chronic hydrocephalus, probably of the 
congenital variety. Her general development will probably always be interfered with. 

I shall now ask you to come to the operating-room and see some cases 
of chronic congenital internal hydrocephalus which Dr. Lovett is about to 
operate upon. 

This first infant (Case 289, I.) is six months old. 

It was noticed when the child was one week old that its head was beginning to increase 
in size. When two months old the circumference of the head is said to have been 41.5 
cm. (162^ inches). Somewhat later the circumference of the head was 44 cm. (17^ inches). 




Congenital internal hydrocephalus. Male, 6 months old. 

and when it was three months old the circumference was 45.5 cm. (18 inches). "When it 
was five months old the circumference was 55 cm. (21f inches). To-day, as you see, it 
measures 57.5 cm. (22| inches). There is no history of syphilis or of tuberculosis in the 
family. The infant has had no marked convulsions, although some twitchings of the hands 
and feet have been noticed. There has been constant nystagmus, and the infant's general 
condition is atrophic. You will notice the marked prominence of the eyes, and the great 
distention of the head. The anterior fontanelle is very large, and the skin covering it is 
distended to such a degree that it is thin and glistening. There is no doubt in a case of 
this kind that aspiration of the cerebro-spinal fluid should be made for the purpose of 
relieving the general condition. 

Dr. Lovett, as you see, has just made an exploratory puncture at the vertex of the 
right side of the head, about 5 cm. (2 inches) from the m.edian line. In place of the small 
trocar he now introduces a larger one. Through this large trocar he has passed several 
strands of silk to serve as a drainage by capillary attraction. You will now notice (Case 
289, II.) after withdrawing the fluid from the right ventricle that the right parietal bone 
has sunk in, its edge being beneath that of the left parietal bone, which is still pushed 
outward by the fluid in the left ventricle. On measuring, a considerable quantity of fluid is 
found to have been aspirated. 

You see that, although the head is very much reduced in size, there are no symptoms 
of collapse nor any other alarming symptoms shown by the infant. 




Congenital internal hydrocephalus after aspiration of right ventricle. 



III. 




^s«*». 







^m \ 



Congenital internal hydrocephalus after aspiration of botli vontnclos. 



ORGANIC NEEVOUS DISEASES. 



641 



(Subsequent history.) The infant was very restless during the following night, tossing 
its head about and crying. 

On the next day 270 c.c. (9 ounces) of clear fluid were withdrawn from the left ven- 
tricle by introducing the trocar at a point corresponding to the point of aspiration of the 
right ventricle. The head was then found to measure 55.5 cm. (22 inches). 

A No. 8 soft catheter was then introduced into each ventricle and sewed into place. 
The external end of each catheter was closed by bending it upon itself and tying it tightly 
with a silk ligature. 

The appearance of the cranium after the second aspiration is here shown (Case 289, 
III.). You will notice the great depression of the anterior fontanelle. 

Three days later 120 c.c. (4 ounces) of fluid were drawn through the catheter. 

On the following day 138 c.c. (4| ounces) of fluid were withdrawn, and the infant was 
found to have a better facial expression. 

On the next day, the fifth after the operation, 105 c.c. (3 J ounces) of fluid were 
removed, and the head was found to measure 51 cm. (20^ inches). 

On the following day Dr. Dane began a series of observations on the fluid-pressure in 
this case, which were the first of the kind that have been brought to my notice. He con- 
nected the catheter with a manometer and found a positive pressure of 7 cm. When the 
iiifant cried the pressure rose to 12 cm. On this day 120 c.c. (4 ounces) of fluid were 
removed. 

On the following day the pressure was found to be 4 cm., and rose to 5 cm. when the 
infant cried. 90 c.c. (3 ounces) were removed. 

On the following day the pressure was the same. 68 c.c. (2^ ounces) of fluid were 
removed on this day, and the head was found to measure 49.5 cm. (19f inches). 

On the following day the infant failed rapidly, had convulsions, became unconscious, 
and died in the evening. 

After death 556 c.c. (18J ounces) of cerebro-spinal fluid were removed. The specific 
gravity of this fluid was 1003. It contained If grammes (28 grains) of albumin to the 
litre. This was measured by an Esbach's albuminimeter. 

The total amount of fluid withdrawn from the ventricles in this case was 720 c.c. (24 
ounces) in seven tappings. 

The next case is that of an infant (Case 290), seven months old, who was admitted to 
the hospital to-day. 

It has always been nursed. When it was two days old it had convulsions. Three 
weeks later it had bronchitis, and accompanying this disease a return of the convulsions, 

Case 290. 




Congenital internal hydrocephalus. Male, 7 months old. 



which occurred as often as six or seven times in the day. Thej^ were localized in the left arm 
and left leg. These convulsions lasted for three weeks, gradually growing less severe. 
There was at this time a certain amount of intestinal disturbance, which, however, has now 
disappeared. There was also a history of a purulent discharge from the ears before the 
infant was admitted to the hospital. It cried out sharply at night. The measurements of 
the head are 56.5 cm. (22f inches) in circumference, and 36.7 cm. (14^ inches) from ear to 
ear over the vertex. The anterior fontanelle is bulging. The eyes, as you see, are markedly 
divergent and protrude from the orbits. If you will observe the eyes closely you will see 

41 



642 PEDIATRICS. 

that there is at times a slight trembling and twitching. No other spasmodic movements 
are noticed. The chest measures 33.5 cm. (13| inches) in circumference. 

You see that the child as it now lies on the operating-table takes no notice of anything. 
It has been decided to relieve the cerebral symptoms by aspiration on account of the 
great increase in the intraventricular fluid shown by symptoms of increased intra-cranial 
pressure. 

As you see, Dr. Lovett has introduced a thoroughly aseptic aspirating needle into the 
right lateral ventricle through the much dilated anterior fontanelle. The aspirating needle 
is connected with a water manometer, which shows a pressure of 30 cm. Having determined 
the pressure by means of this water manometer, we can now remove a certain amount of 
the fluid. In order to do this, a whiff" of ether is given to the infant, and you see that Dr. 
Lovett introduces a trocar in place of the aspirating needle. He then withdraws the 
trocar, leaving the canula in the cavity. Next, as you see, he introduces a No. 7 soft 
rubber catheter through the canula, and on withdrawing the latter the end of the catheter 
is left in the ventricle. 130 c.c. (4J ounces) of clear fluid have been removed from the ven- 
tricle. The specific gravity of this fluid is 1006. You perceive that the axes of the eyes, 
which before the operation were divergent, are now parallel. The external end of the 
catheter is now closed in the same manner as you saw it done in the preceding case. 

(Subsequent history.) The observations on the intra-cranial pressure in this case, as in 
the last (Case 289) , were made by Dr. John Dane. On the day following the operation the 
pressure was found to be 14 cm. by the water manometer. When the child cried it was 
increased to 20 cm. 25 c.c. (f ounce) were removed on this day, and the circumference of 
the head was then found to be 35 cm. (13| inches). The specific gravity of this fiuid was 
1007. 

On the second day after the operation the pressure was found to be the same. At that 
time 55 c.c. (1| ounces) of fluid were removed, the speciflc gravity of which was found to 
DC 1006. 

On the third day after the operation the tube was found to have leaked a little, and 
there was a slight convulsion in the morning. 50 c.c. (If ounces) of fluid were removed. 

On the following day the tube was found to be leaking freely, and the infant was in a 
state of collapse and refused to nurse. The head measured 52 cm. (20 J inches). 

On the next day there was still some leakage around the tube, but the infant was in a 
better condition. 

Three days later, the leakage around the tube having been controlled in the mean time, 
the infant seemed better, but it had a thick purulent discharge from both ears. 

During the next few days the child began to grow weak, and there was again a slight 
leakage around the tube. 

On the eleventh day following the operation the child died quietly, no convulsive 
symptoms having appeared. 

There was no complete post-mortem examination, but the distended ventricles were 
found to contain 759 c.c. {25^ ounces) of clear straw-colored fluid, — the left ventricle con- 
taining 409 c.c. (13f ounces) and the right 350 c.c. (llf ounces). An examination of this 
fluid by Dr. J. H. Wright showed that it was turbid with a flaky sediment. It was slightly 
alkaline. The specific gravity was 1009. It contained about 0.1 per cent, of albumin. 
No sugar was found. Under the microscope nothing was seen resembling the lining cells 
of the ventricles. An inoculation of a guinea-pig with this fluid to determine whether it 
was of a tubercular nature or not gave negative results. 



Acquired Internal Hydrocephalus. — Both the acquired and the con- 
genital form of internal hydrocephalus may be of mechanical or inflammatory 
origin, but the acquired form shows evidence of an inflammatory condition 
oftener than does the congenital form, and occurs very frequently in con- 
nection with rhachitis. Acquired internal hydrocephalus may be acute or 
chronic. In its acute form it may occur at any age as a symptom of any 



ORGANIC NERVOUS DISEASES. 643 

one of a number of diseases, such as meningitis, one of the exanthemata, 
pertussis, and rhachitis. It may in any of these forms become chronic. 
The disease may sometimes appear to be idiopathic. 

The chronic form of acquired internal hydrocephakis occurs usually in 
the first four years of life, and is represented pathologically by a small 
amount of intra-ventricular fluid, perhaps 100 or 200 c.c. (3J to 6f ounces). 
It is this chronic form of acquired internal hydrocephalus that can best be 
classified under the name of hydrocephalus with the congenital internal 
hydrocephalic cases which I have just shown you. 

Symptoms. — The symptoms of the acute form of acquired internal 
hydrocephalus are so closely connected with the diseases in which it occurs 
as a symptom that it is not necessary to speak of them here. 

The symptoms of chronic acquired internal hydrocephalus are very 
much the same as those of the congenital form. The firmer the union 
of the bones the less likely is enlargement of the head to occur. 

Prognosis. — The prognosis as regards life is serious. Of those who 
recover, many are left either with some mental defect or with permanent 
blindness, the latter the result of optic atrophy. Complete recovery may 
occur, but is exceedingly rare. 

Diagnosis. — The diagnosis of chronic acquired internal hydrocephalus 
of the idiopathic form is in its earlier manifestations chiefly made by the 
elimination of other cerebral diseases, though after the stage of inflamma- 
tory irritation has passed and the symptoms of pressure have become estab- 
lished, a provisional diagnosis can usually be made. I say provisional 
because the disease is rare, and a sufficient number of autopsies have not 
yet been made to justify a decided diagnosis such as can be made in the 
congenital form of the disease. 

Treatment. — The treatment is purely symptomatic in cases where the 
sutures and fontanelles have completely closed, except where it is advisable 
to perform craniectomy. Where they have not closed, the treatment is the 
same as in the congenital form, — that is, usually operative. 

I have here three cases which I feel justified in reporting to you as 
probably representing chronic acquired internal hydrocephalus. Of course 
in these cases we must allow that a tubercular or syphilitic taint may have 
been the starting-point of the intra-ventricular disease. 

A boy (Case 291), four years and eight months old, was seen by me in consultation with 
Dr. E. J. Forster, May 27, 1885. The child's parents were healthy ; his mother had other 
healthy children and had had no miscarriages. The child had always been well, measles 
being the only disease which he had ever had. At the age of six months, while in the 
process of cutting a tooth, he had three convulsions, from which he recovered entirely. 
His appetite had always been capricious, but his digestion was good. His bowels had 
always been regular. He had lately come from a malarial region, where he had lived in 
a rather damp dwelling for a year. 

On May 6 he vomited twelve or thirteen times. The vomiting then stopped, but 
returned later from time to time. He complained of pain in his stomach, had no fever, and 
sometimes appeared to feel chilly. His bowels were constipated, and in the beginning of 



644 



PEDIATRICS. 



the attack his pulse was slow. He had been subject to night-terrors for some time previous 
to this sickness. The vomiting had lessened by May 27, and the report of my examination 
on that date is as follows : 

Pulse 60, rhythmical ; respirations regular ; temperature normal ; has had earache 
lately ; no discharge from the ear since he was an infant ; the examination of the ear was 
negative ; yesterday morning he had a general clonic convulsion lasting for some time ; his 
tongue is slightly coated ; he lies in an apathetic state, though perfectly conscious ; he is 
losing in weight and strength and has lost his appetite ; urine normal. Nothing abnormal 
is found on examination of the thorax or abdomen. (The examination of the eyes, June 15, 















Chart 


24 














Days of Disease 


F. 


21 


22 


23 


24 


25 


26 


27 


28 


29 


30 


31 


32 


33 


<J. 


107° 
106° 
105° 
104° 
103° 
102° 
101° 
100° 
99° 

NOKWl 

TEMP. 

98° 

97° 

96° 
95° 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


41.6° 

41.1° 

40.5° 

40.0° 

39.4° 

38.8° 

38.3° 

37.7° 

37.2° 
37.0° 
36 6° 

36 1° 

35 5° 
35.0° 






























































































































































































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1 


















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■/ 


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-S^ 


«^ 


V 


y^ 


b;^ 


^ 


^ 


X^ 


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150 

140 

130 

120 

110 

100 

90 

80 

70 
60 




























J 










































































































































1 










h 




[ 






/ 




y 


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Chronic acquired internal hydrocephalus. 



by Professor O. F. Wadsworth, showed that there was much swelling of the optic nerve, 
increased prominence of the retinal vessels, hemorrhages, and neuritis.) The child seems 
much brighter, and plays about. His intelligence is perfectly good ; he has had no more 
convulsions and no paralysis, and seems perfectly well, except that his pupils are dilated 
and he is totally blind. The accompanying chart (Chart 24) records his temperature and 
pulse from May 27 to June 9. 

This child came to see me in May, 1893, when he was twelve years old. He had been 
and was at that time perfectly well. He was a bright, well-developed, healthy boy, twelve 
years old. His pupils reacted, but he had never recovered his sight. He weighed 19.8 



ORGANIC NERVOUS DISEASES. 645 

kilogrammes (90 pounds). His bowels were regular; his appetite was good. His knee- 
jerks were not increased. His head measured 49 cm. (19^ inches). 

I shall now call your attention to this little girl (Case 292), ten years old, who has been 
in the hospital for about two months. Her family history is negative, with the exception 
that two maternal aunts died of phthisis. The child has never had any disease except 
bronchitis, measles, and varicella. Her present trouble began one and a half years ago with 
at first attacks of loss of consciousness without convulsions, lasting half an hour, after which 
she would fall asleep for some time. Eighteen months ago these attacks began to be accom- 
panied by convulsions, which usually came about once a month, the intervals sometimes 
being three or four months. The duration of the convulsions and the following sleep were 
about the same as in the earlier attacks. These convulsions have now not occurred for six 
months, with the exception of one slight attack five weeks ago, when the right eye twitched 
and there was a momentary loss of consciousness. The convulsions began with twitching 
in the right eye, followed by twitching of the right hand. The rest of the body was not 
aflected. The attacks were ushered in by intense headache, sudden vomiting, fever, flushed 
face, and retraction of the head. The headaches, which began about one year ago, were 
extremely severe and caused her to scream with pain. They were felt all over the head, 
but especially in the region of the occiput ; they would last an hour or more, until she 
vomited and then fell asleep. They came about every day, but were not always accom- 
panied by vomiting. The headaches ceased altogether for a time, but she has had two or 
three in the past five weeks. She has lately complained of dimness of vision. Six weeks 
ago she had pains in her right hand between the fore and middle fingers and began to 
lose the use of her hand. Physical examination reveals, as you see, nothing definite. She 
is more awkward in using her right hand than her left, but all motions, you will perceive, 
are possible and strong. Her right foot seems to drag a little and is a little weak after run- 
ning, but these symptoms are not especially marked. The sensation of the hand is normal; 
the knee-jerk is somewhat increased. For the past six weeks she has shown evidence 
of facial paralysis. Her pupils at times have been widely dilated. Dr. Dixon reports an 
atrophy of both disks, with slight myopia. 

Case 293. 




Acquired internal hydrocephalus. Protrusion of eyes. 

She has been sleeping poorly, and has had a fair appetite ; the temperature has been 
about 37.7° to 38.3° C. (100° to 101° F.) ; the pulse 96 and regular; the respirations 24 
and regular. She was treated with a good general diet and 0.30 gramme (5 grains') of 
bromide of potassium three times a day. The bromide was omitted one month ago. Lately 
she has seemed to be much better, and, as you see, she is now looking very well. 

This little boy (Case 293, I.) is two and a half years old. 



646 



PEDIATRICS. 



He is said to have been well and strong at birth, and never to have been sick until two 
months ago, when he woke up screaming in the night, and this was followed by convulsions. 
For two weeks he did not recognize any one, cried out at times, and micturition and defeca- 
tion took place unconsciously. In the early days of the attack he lay immovable. After 
consciousness returned he improved for five or six weeks, and no other especial abnormal con- 
dition developed. Two weeks ago he was attacked with convulsions, occurring at intervals 
of from thirty-six to forty-eight hours and lasting from one to one and a half hours. These 
attacks were ushered in by crying, which was followed by loss of consciousness, opisthotonos, 
kicking, and finally clonic convulsions. His mother states that during the early weeks of 
the disease he shrieked at times continuously and evidently suffered the most acute pain, 
apparently in the head. 

Case 293. 




Acquired internal hydrocephalus. Kernig's symptom. Male, 2^.2 years old. 



On examining the child, you see that he is well developed and nourished. The an- 
terior fontanelle is still open. The fronto-parietal suture on the right side of the head is 
quite distended. His forehead is rather bulging. His eyes are somewhat prominent, and 
rather depressed in the orbits. The pupils are dilated. The head measures 47.3 cm. (18| 
inches) in circumference, 33.2 cm. (13^ inches) from glabella to inion, 27.2 cm. (lOf inches) 
from ear to ear. The circumference of the chest is 49.7 cm. (19|- inches). There is a 
slight hemiplegia and paresis of the right arm and leg, but objects can be grasped with the 
right hand. He cannot walk. There are no enlarged glands. Nothing abnormal is found 
on examination of the heart, lungs, or spleen. The knee-jerks are increased, the right one 
more than the left. There is no ankle-clonus. The teeth are in good condition. 

On placing the child on the edge of a table (Case 293, II.), you will see that both the 
legs become stiffened (Kernig's symptom). 

The child seems to be fairly bright and to be improving every day. He is much less 
fretful than formerly. An examination of the eyes by Dr. Jack shows a beginning atrophy 
of the optic nerves, with retinal hemorrhages of the left eye. 



ORGANIC NERVOUS DISEASES. 



647 



The child's temperature has varied usually from 37.7° to 38.3° C. (100° to 101° F.). 
The pulse has been regular and somewhat quickened. 

The diagnosis of this case is evidently one of intra-cranial disease. The disease was 
acute in its onset, and was accompanied by extreme pain in the head, convulsions, and 
unconsciousness, followed by a partial paralysis of the arm and by loss of the power of 
walking. The protrusion of the eyes would indicate intra-cranial pressure, and the paralysis 
some intra-cranial lesion, possibly of mechanical origin. What the nature of the original 
attack was cannot now be determined, but it was evidently of an acute inflammatory type, 
and it seems as though it must have been connected with an inflammatory condition prob- 
ably affecting the ventricles. Following this inflammatory condition, the symptoms indi- 
cate an intra-ventricular effusion, and I think we can therefore assume that, whatever the 
original cause of the disease was, the child may now be said to have chronic acquired 
internal hydrocephalus. 

(Subsequent history.) During the following year the child improved slowly but 
markedly. He became less fretful ; he learned to talk better, and finally to walk. His 

CHAET 25. 



Days of Disease 


F. 

107' 

106' 

105° 
104° 
103' 
102° 

101° 
100' 
99' 

NORML 

TEMP. 

98" 

97° 

96° 
95' 


ME 


ME 


ME 


ME 


ME 


MB 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


MB 


:me 


ME 


ME 


ME 


ME 


ME 


G. 

41.6° 

41.1° 

40.5° 

40.0° 

39.4° 

38.8° 

38.3° 

37.7° 

37.2° 
37.0° 
36 6° 

36.1° 

35.5° 
35.0° 
















































































































































































/ 




1 




/ 


































/ 




/ 


/ 


/ 




J 




/ 


/ 






/ 
















/ 


/ 


^ 


/ 


/ 


V 


/ 


\ 


/ 


/ 


/ 




/I 


/ 


/ 




/ 


rl 


y 


/ 


/ 


Y 


y 












y 


/ 


y 


/ 




1/ 


V 


/ 




/ 








..... 










-.._, 

















V 








v.. 




..... 

































































































































Chronic acquired internal hydrocephalus. Male, 2% years old. 



temperature became normal, and when last seen, at the asje of three and a half years, he 
seemed to be perfectly well, the paralysis of the arm and hand having almost disappeared. 
Here is the temperature chart (Chart 25), showing the course of the temperature for 
twenty-one days in the third month following the original attack. 



648 PEDIATRICS. 



IvKCTTURK XXXI. 

BRAIN.— (Concluded.) 

Cerebral Abscess. — Cerebral Paralysis. — Athetosis. — Intra-Cranial Tumors. 
— Intra-Cranial Syphilis. — Idiocy.— Mirror Writing. 

CEREBRAL ABSCESS. — Cerebral abscess is a localized purulent 
encephalitis. It is probably always secondary to suppurative disease else- 
where. It may arise from a suppurative condition of the scalp, but its most 
common source is some purulent disease of the ear or its surroundings. It 
is also found as a sequel to traumatism of various kinds resulting in suppu- 
ration and in general pyaemia, and it may follow direct traumatic injury 
to the brain. Cerebral abscess is usually single, except when it is produced 
by pysemia. Although the abscess may occur in any part of the brain, a 
very common locality is in the cerebellum. 

Symptoms. — A cerebral abscess may exist for a considerable time with- 
out producing any symptoms which can be recognized during life. In cases 
where suppurative disease of the ear exists, a cerebral abscess may be 
suspected where, in addition to the temperature, which would naturally be 
raised from this process, the child's general condition becomes worse without 
any apparent cause, and where indefinite symptoms, such as mental dulness 
and irritability, arise. The temperature may also suggest the presence of 
imprisoned pus, and the probability of cerebral disease, in cases where the 
pus cannot be found elsewhere. Cerebral abscess may, however, exist for a 
considerable period without rise of temperature, and even with a subnormal 
temperature. It is apt to be slow in its progress and to cause general con- 
stitutional rather than local symptoms. liocal symptoms produced by the 
presence of cerebral abscess are rare. When present, however, they are 
represented by headache, vertigo, mental dulness, vomiting, and convulsions, 
and are followed later by coma. When the abscess bursts into the ven- 
tricles, symptoms of sudden collapse appear, and death rapidly follows. 
Tremor and convulsions may occur in cases of cerebral abscess, but neither 
of them should be considered as in any way symptomatic of this condition. 

Prognosis. — The prognosis is very unfavorable unless the disease can 
be reached surgically. 

Treatment. — The treatment should be operative if the abscess can be 
localized. 

CEREBRAL PARALYSIS. — In using the term cerebral paralysis 
it must be understood that it is not intended to describe every disease of 
intra-cranial origin from which a paralysis may result. We may have a 
resulting paralysis from many intra-cranial lesions, such as hydrocephalus, 



ORGANIC NERVOUS DISEASES. 



649 



cerebral abscess^ cerebral tumors^ and other causes. The class of cases 
which I am about to describe under cerebral paralysis occurs usually in 
children under three or four years of age. In a certain proportion of these 
cases hemorrhage^ embolism, and thrombosis are the causes of the acute 
symptoms. Most of the autopsies which have been made have shown 
sclerosis, atrophy, or porencephalia, which are probably secondary rather 
than primary. In these latter cases the original primary cause is not 
known. Cerebral paralysis results in a spastic paralysis involving one 
or more extremities, and may be in its distribution monoplegic, hemi- 
plegic, paraplegic, or diplegic. 

Etiology and Pathology. — I shall first speak of the three known 
primary causes which I have just mentioned, — namely, (1) hemorrhage (rup- 
ture of one or more blood-vesssls), (2) embolism (a foreign body brought to 
the brain from some distant part of the circulatory apparatus), and (3) 
thrombosis (an occlusion of one or more of the cerebral blood-vessels by a 
local coagulation of the blood). 

Fig. 95. 




Br., Brain. Hem., Hemorrhage. Ar., Arachnoid. 

Of these three known primary causes hemorrhage is the most common. 
This hemorrhage is more apt to be meningeal than cerebral. It is for this 
anatomical reason that these cases of hemorrhage in infants are less liable to 
prove fatal than those which occur in adults. I have already described to 
you a case (Case 186, page 449) of presumably meningeal hemorrhage in 
an infant three days old. This case illustrated the possibility of recovery in 
even severe cases of intra-cranial hemorrhage. 

Through the kindness of Professor Northrup I am enabled to sho^^' you 
this specimen (Fig. 95) of a case of meningeal hemorrhage in an infant 
born prematurely at the eighth month. 



650 PEDIATRICS. 

The mother had puerperal convulsions, and the delivery was by for- 
ceps. You see that the hemorrhage is in the locality where it is usually 
found in such cases, the subarachnoid space (vide Diagram 8, page 594). 
Intra-cranial hemorrhage in the infant and the young child may arise from 
various causes, such as increase of the intra-cranial pressure from various 
diseases, which produce stasis of the blood-current, or from traumata, whether 
from pressure or from direct injury to the skull and the brain. In addition 
to these causes, certain changes in the blood-vessels themselves, represent- 
ing an atheromatous condition, are supposed to give rise to intra-cranial 
hemorrhage. Certain forms of degeneration may cause such a disorganiza- 
tion of the walls of the cerebral blood-vessels as to result in hemorrhage. 
In this latter class syphilis is a factor which must be considered, as must also, 
according to Sachs, general tuberculosis, meningitis, and cerebral tumors. 

Next to hemorrhage, embolism is the most common cause of this class 
of cerebral paralysis. So few cases, however, have thus far been satisfac- 
torily investigated by post-mortem examinations that I shall not dwell upon 
this condition, nor upon the still more rare resulting pathological lesion, 
thrombosis, except to explain that the emboli and thrombi act by cutting 
oif the blood-supply of a certain portion of the brain, thus producing the 
disintegration of the cerebral tissue and the resulting paralysis. 

As I have used the terms sclerosis and porencephalia, it may be well to 
define them. 

Sclerosis consists of a shrinking and hardening of the cerebral tissues 
usually more or less strictly localized. 

Porencephalia denotes a pathological hollow or depression in the brain 
running from the cortex towards the centre and usually communicating with 
a lateral ventricle. 

The general pathological conditions to be remembered in cerebral paral- 
ysis, no matter what the original lesion, as has been so clearly summarized 
by Lovett in his paper on ^' Cerebral Paralysis in Children,'' are, first, a 
lesion of the brain involving, as a rule, some portion of the motor tract ; 
and, second, atrophy and retarded development of the brain, with a descend- 
ing degeneration of the lateral columns of the cord and pyramidal tracts. 
Finally, there is a possibility that the cause may be a defective development 
of the nervous centres. 

Cerebral paralysis may occur in connection with a number of diseases, 
such as the acute exanthemata, pertussis, diphtheria, parotiditis, typhoid 
fever, and after continued convulsions. Difficult parturition, with or with- 
out the use of forceps, seems to be responsible for a certain number of the 
spastic cases, both paraplegic and hemiplegic. 

Symptoms. — Having made this preliminary explanation of the kind 
and extent of the knowledge which I am endeavoring to convey to you 
concerning the cerebral paralyses of infants and young children, I can now 
state the important general features of the disease which I should like to 
have you remember. 



ORGANIC NERVOUS DISEASES. 651 

If the lesion has been of intra-uterine origin, we may get only the later 
manifestations of this lesion, just as we do in congenital syphilis. In like 
manner, if the lesion has occurred at the time of delivery, the primary 
symptoms are often masked, and the resulting symptoms of the more 
advanced pathological condition are noticed later. 

Where the disease develops in extra-uterine life it is usually acute in 
its character and is marked by more or less fever, convulsions, and stupor. 
These early symptoms are merely those of a general nervous explosion fol- 
lowing an irritation of the nervous motor centres. They may be the first 
manifestations of a disease of any kind, or they may occur in the course of 
one of the diseases of which I have spoken under etiology. If they happen 
to occur at night and are of short duration, they may be entirely overlooked, 
and the later symptoms of a cerebral lesion may be the first ones to mani- 
fest themselves. The child may die from the severity of these initial lesions 
before the later symptoms of paralysis have developed by which we can 
diagnosticate the disease. Screaming, vomiting, and delirium may at times 
usher in the attack. In the midst of or closely following these primary 
symptoms come the pronounced indications of a central nervous lesion, 
represented by hemiplegia (paralysis of an arm and a leg on the same side), 
paraplegia (paralysis of both legs), or diplegia (paralysis of both arms and 
both legs), cases of hemiplegia being the most common. In rare cases we 
find only one extremity affected (monoplegia). 

In addition to the paralysis of the limbs, facial paralysis may occur either 
in hemiplegia or in diplegia, and, as a rule, spares the upper part of the 
face, so that the eyes can be closed and the brows raised, thus showing that 
it is not a peripheral facial paralysis. This form of facial paralysis often 
disappears early. 

On examining the paralyzed limb we find a resistance to motion, the 
deep reflexes are exaggerated, and in most cases there is a feeling of rigidity 
on the paralyzed side. A few cases of flaccid paralysis have been reported. 
Sensation, as a rule, is not affected. When the child has come out of its 
stupor and the convulsions have ceased, it may be found to be aphasic. The 
intelligence is usually impaired, but this, of course, depends upon the loca- 
tion and extent of the lesion and the period when it occurred. 

The intra-uterine and early infantile cases show the greatest mental dis- 
turbance. These children are apt to be very irritable, and, where the lesion 
is cortical, epileptiform convulsions are quite common. The electrical re- 
action of the muscles is normal. In the more advanced stages of cerebral 
paralysis additional symptoms begin to appear. The child learns to walk 
late, or, if it has already walked, the gait becomes peculiar. Rigidity fol- 
lowed by contracture of the flexor and adductor muscles may occur. In 
certain cases the spastic condition is so pronounced that tlie patellar tendon 
reflex and the ankle-clonus cannot be obtained. When walking is attempted, 
the patient is apt to stand on tlie toes, the knees knock together, and the 
spastic rigidity of the muscles produces what is called the spastic gait, 



652 PEDIATEICS. 

represented in its exaggerated form by the cross-legged progression, which 
i.« largely caused by the rigidity of the adductors of the thigh, and illustra- 
tions of which I shall presently show and explain to you. 

The term spastic gait is applied to the peculiar way in which these chil- 
dren walk. In the more severe cases, when the child is placed upon his feet 
the contraction of the flexor muscles is excited to such a degree that he is 
unable to touch his heels to the ground, and stands on the ball of the foot 
and the toes, with his knees bent. This results in a clinging labored walk, in 
which the child's toes scrape along the ground and the feet tend to knock 
against each other on account of the contraction of the adductor muscles. 

In the milder cases the same manner of progression occurs, but is more 
sudden and jerky, and the foot can be raised from the ground. Much un- 
steadiness thus results in these cases. 

The affected limbs are apt to show some disturbance of their circulation, 
and some coldness. There are more or less atrophy and shortening of the 
bone, but to a less degree than in cases of poliomyelitis anterior. In a 
certain number of cases involuntary inco5rdinate movements are excited in 
the paralyzed limbs on voluntary effort (hem i ataxia. Osier), and are usually 
designated as post-hemiplegic chorea. There may also be continuous move- 
ments (athetosis) of either a partial or a general variety. The sphincters 
are not affected, whether the case is one of hemiplegia or of paraplegia. The 
epileptiform convulsions which I have already referred to may appear quite 
early in cases of cerebral paralysis, but may also be delayed for a number 
of years, so that the possibility of these children becoming epileptic must 
always be considered. 

Diagnosis. — The general diagnosis of cerebral paralysis without regard 
to the special cause is of great practical importance to the practising physi- 
cian, and should be thoroughly mastered before he attempts to diagnosti- 
cate the exact nervous lesion or to locate it with the precision of the skilled 
neurologist. 

The diagnosis in a marked case of the disease is not difficult, but the 
determination of the exact lesion is often impossible after the period of onset 
has passed and we are left with a resulting paralysis. If facial paralysis is 
present, we can, as a rule, say that the lesion is in the brain ; but this rule 
does not always hold good, as there have been very rare cases where this 
paralysis was present when the lesion was in the cord. 

The symptoms on which we chiefly rely in making our diagnosis of cere- 
bral paralysis are (1) the distribution of the paralysis, hemiplegic usually or 
paraplegic ; (2) increased tendon reflex ; (3) wasting comparatively slight ; 
(4) normal electrical reaction ; and (5) mental impairment. 

The principal disease from which cerebral paralysis is to be distinguished 
is poliomyelitis anterior, and I shall in a later lecture when speaking of that 
disease explain to you the symptoms by which we can make a differential 
diagnosis between the two diseases by means of a table (Table 104, page 
679). For the purpose of clearness, however, I will also state here that, in 



ORGANIC NERVOUS DISEASES. 653 

contradistinction to the chief diagnostic symptoms of cerebral paralysis 
which I have just given you, you will find in poliomyelitis anterior (1) that 
the distribution of the paralysis is usually monoplegic ; (2) that there is an 
absence of tendon reflex ; (3) that there is an absence of rigidity in the early 
stages ; (4) that there is rapid and marked wasting of the affected limbs ; 
(5) that the reaction of degeneration is present ; and (6) that there is no 
mental impairment. 

In certain cases also a difficulty may arise in correctly understanding the 
relationship between cerebral paralysis and idiocy. The cerebral lesion is in 
many cases probably the same, but, according to its extent and location, we 
may have either (1) a cerebral paralysis alone; or (2) a cerebral paralysis 
accompanied by mental impairment or idiocy ; or (3) idiocy without cerebral 
paralysis. There is a certain class of low-grade idiots in which some 
impairment of motion exists, apparently due to a mental inability to coordi- 
nate the muscles of the limbs properly. This may sometimes be accom- 
panied by a diminution of sensation, which seems to be due to a want of 
perception in the higher nervous centres rather than to any actual lesion of 
the sensory tract. When the idiof s attention can be kept centred on the 
limb, the actual sensation does not seem to be much impaired. The differen- 
tial diagnosis of this condition occurring in idiots from cerebral paralysis is 
easily made, for it exists in those cases only of the former where the mental 
development is much impaired, and it is not, as a rule, accompanied by true 
paralysis, as there is no weakness, but simply incoordination ; in these cases 
also the tendon reflexes are, as a rule, not increased. 

Cerebral paralysis can be diagnosticated from the paralysis which occurs 
in connection with caries of the spine, principally by the presence of cere- 
bral symptoms in one case and the prominence of the spinal vertebrae and 
the rigidity of the spine in the other. 

I should also mention here that the rare cases of syringomyelia may 
be mistaken for cerebral paralysis. The points of differential diagnosis in 
these cases are that in syringomyelia, although the weakness of the limbs 
may be so extensive as closely to simulate paralysis, yet the diminution of 
thermic sensation, which I shall presently speak of when describing the 
•disease to you (page 690), easily distinguishes it from the normal sensa- 
tion which is present in cerebral paralysis in cases where the test for sen- 
sation can be employed. The disease, however, is so rare in children that 
it need not be dwTlt upon. 

Prognosis. — The question which immediately arises when the physician 
is confronted with a case of paralysis in an infant or a child is. What will 
be the result of this attack ? not, What is the special anatomical lesion which 
is causing it ? Knowing, as I shall presently explain to you, that where the 
lesion is of spinal origin the chances for recovery are fairly good, you will 
at once appreciate the vast difference whicli your answer may make to those 
interested in the child when you state tliat the disease is in the cord and 
that recovery is probable up to a certain point without mental impairment, 



654 PEDIATRICS. 

rather than that the brain is involved and possibly mental as well as physi- 
cal incapacity for life may result. The prognosis for life in cerebral paralysis 
is soon determined in the early days of the attack, and of course depends on 
the location and extent of the cerebral lesion. Entire recovery is rare. The 
leg, as a rule, recovers more rapidly and to a greater extent than the arm, 
which seldom regains its entire usefulness. The spastic rigidity usually 
goes on to decided contracture. In some cases no mental change is apparent ; 
in others the mental development is merely retarded, and the child learns to 
talk some years later than is normal. In a large number of cases, however, 
the mind is much enfeebled. The occurrence of epilepsy as a result of 
cerebral paralysis is so common that it should be especially mentioned in 
this connection, as it makes the prognosis much more serious both as to the 
degree to which the mental impairment may attain and as to the life of the 
patient. 

Except in very rare cases, the children can be taught eventually to walk. 

Treatment. — The treatment of cerebral paralysis must necessarily be 
unsatisfactory. It is to be directed to keeping the paralyzed limbs in as 
good a condition as possible and thus avoiding contractures of high grade. 
This can be accomplished in a measure by patient and continued massage 
and manipulation, chiefly in the direction of stretching the flexor muscles 
and cultivating the use of the extensors. The faradic current used three or 
four times a week for five or ten minutes is a useful adjuvant, and, if neces- 
sary, surgical interference to relieve undue tension of the flexor tendons is 
indicated. 

The mental training of these cases is exceedingly important, and should 
be attended to carefully. In this connection it is well to remember that the 
division of the contracted tendons in some way seems to improve the mental 
condition. Trephining the skull over the supposed seat of the lesion does 
not, with our present knowledge of the usual nature of these lesions, pre- 
sent a particularly encouraging outlook. The few cases which have been 
operated upon have not been benefited. 

It should be thoroughly understood that surgical operations to relieve the 
contractures do not influence favorably any pre-existing paralysis or incoor- 
dination, but that it often puts the limbs in a condition in which massage 
and electricity can be applied to greater advantage. The indications for the 
division of the tendons of the contracted muscles exist when the contrac- 
ture is so firm that thorough treatment by massage and electricity produces 
no essential relief. Cutting the tendons in cases of low grades of idiocy has 
usually been considered contra-indicated, but this opinion is not shared by 
all observers, as in a certain number of cases at the Boston Children's 
Hospital decided benefit has been found to result. 

I have thus endeavored to give you a precise and practical idea of a very 
complicated subject. In order to do this I have used as few names as pos- 
sible and have avoided many plausible but theoretical explanations of noted 
writers. As an instance of this, I have passed over Striimpell's brilliant 



ORGANIC NERVOUS DISEASES. 655 

but unproved theory of polioencephalitis as one of the causes of cerebral 
paralysis. You will, however, now understand how inadequate are the 
various names, such as spastic paralysis, spastic rigidity, spastic diplegia^ 
Little's disease, and infantile hemiplegia, to cover the broad range of pathology 
and symptoms which is represented by the class of cerebral cases which I 
have designated under the general term cerebral paralysis. 

I have a number of cases here to show you which represent this condi- 
tion of cerebral paralysis in children. 

The first case is a boy (Case 294) , five years old. Up to the age of seven months he is 
said to have been in a normal condition. The disease which was followed by the symptoms 
which he now presents occurred when he was seven months old. At this time he was 
attacked with fever and a convulsion, and later was found to have paralysis of the right arm 
and both legs. 

Case 294. 




Cerebral paralysis. Right hemiplegia, with affection of opposite leg. Male, 5 years old. 

On examining the child you see that the thumb is turned in on the palm of the hand 
and the fingers are slightly flexed and at times slightly extended. Both legs are somewhat 
flexed at the knees. The hamstring tendons are tense and unyielding. The knee-jerks are 
increased. The heels are raised from the ground. 

This child is a case of hemiplegia with afiection of the opposite leg. 

In mild cases of this kind the treatment is by massage and electricity ; in the more 
severe forms apparatus is required. In a very severe form like this, operative interference 



656 



PEDIATRICS. 



is necessary before massage, electricity, or apparatus can he applied with advantage. 
In this case division of the hamstring tendons and of the Achilles tendons is indicated. 
Operative proceedings in cases of this kind must be recognized as only rectifying the posi- 
tion and preparing the limbs for further treatment by massage, electricity, and apparatus. 

The next case (Case 295) is a girl, five years old. 

She has a good family history. The labor was easy, and was not instrumental. She 
developed well and was healthy until she was ten months old, when it was noticed that 
she did not move her arms as she ought to, that she did not use her left arm at all, and that 
the left leg was not used as well as the right. This condition has persisted. 

Case 295. 




Cerebral paralysis. Diplegia. The left extremities affected more than the right. Female, 5 years old. 



On examination you see that she has strabismus. She cannot hold her head up straight. 
She cannot sit up alone or stand. Her head is small and narrow, and has a long antero- 
posterior diameter. The reflexes are increased. The power of her left arm is much im- 
paired, and there is some contraction of the fingers and elbow of a spastic character. She 
does not move her left leg well. The sensation is dulled alike in both legs. Her face has 
an idiotic expression, she is poorly developed mentally, and she cannot talk. 

She shows the form of spastic cerebral paralysis which is called diplegia, the left 
extremities being more afiected than the right. The face is not involved in this case. 

The prognosis of a case like this is unfavorable so far as recovery is concerned, on 
account of the great mental impairment. Operative treatment is, however, indicated, as at 
times improvement results in even decidedly idiotic cases. 



ORGANIC NERVOUS DISEASES. 



657 



This little girl (Case 296), two years old, was born after a severe instrumental labor. 

She has always from birth shown weakness of the arms and legs. She was unable to 
sit up until she was a year old, and she has never stood or walked. Her intelligence is 
apparently normal. You see that the cranium is normal in shape, that the parietal emi- 
nences are somewhat enlarged, and that the fontanelle is still open. There is no disturb- 
ance of the facial muscles. The right leg is slightly larger than the left. The teeth are 
in excellent condition. The upper extremities appear alike, but she cannot loosen her 
fingers after grasping an object with her right hand. The epiphyses of the wrist are much 
enlarged, and those at the ankles are slightly so. There is no definite rosary. The back is 

Case 296. 




Cerebral paralysis. Congenital cerei)ral diplegia aud rhachitis. Female, 2 years old. 



somewhat rigid. There is no marked deformity. There is a tendency to rigidity in both 
lower extremities. The feet are inverted. The patellar reflexes are increased. Sensation 
is normal. She can use her hands well, except as above described. 

She represents the class of cerebral paralysis which is called cerebral diplegia. You 
see that she is also rhachitic. 

Here is a little boy (Case 297, page 658), four years old, who was perfectly well at 
birth, but who when he was six months old had a number of convulsive attacks without 
any known cause. 

When he was two years old he had an attack of measles, followed by varicella, and 
later by pertussis. He has never been able to sit or stand alone. He is fairly developed 
and nourished, and his intelligence is normal. He has marked general kyphosis when 
supported by the arms. When he is assisted to walk he also shows the condition of cross- 
legged progression. The arms are somewhat stitf, and he holds the forearms slightly 
pronated. The triceps reflex is somewhat increased. The legs are usually hold somewhat 
flexed on the body, and the knees are also slightly flexed, with the feet in the position of 
slight equinus. The knees are held closely together. Rigidity is less marked in the right 

42 ^ ' 



66S 



PEDIATRICS. 



leg than in the left. The patellar reflexes are much increased, and ankle-clonus is present. 
There is very marked rigidity of the left side, so that the reflexes are obtained with 
difficulty. 

The treatment in such cases as this, where there is no mental impairment, should be 
operative. Section of the adductors of the thigh, of the flexor tendons of the knee, and of 
the Achilles tendons is indicated. 

This next boy (Case 298), five and one-half years old, has nothing in his family history 
that bears upon the disease with which he is afiected. 

Nothing of an abnormal nature was noticed about him until he was ^fteen months old. 



Case 297. 



Case 298. 




Cerebral paralysis. Diplegia. Cross-legged progres- 
sion. Male, 4 years old. 



Cerebral paralysis. Spastic paraplegia. Cross- 
legged progression. Male, 53^ years old. 



when it was found that he could not walk. He had more or less mental impairment, nys- 
tagmus, stiffness of the adductor and flexor muscles, and paresis of the extensors of the lower 
extremities. The knee-jerks are much increased, and there is slight ankle-clonus. He walks 
in the characteristic manner called cross-legged progression. 

When an infant he evidently had some cerebral lesion, and he represents very well 
what I have explained to you as spastic paraplegia. There will probably never be any im- 
provement in his physical condition, and his mental state will always be unsatisfactory. 

This boy (Case 299), six years old, has no history of any hereditary disease. 

He was healthy at birth, but the labor was a severe one, and was terminated with in- 
struments. He developed normally during the first two years of his life, and walked when. 



ORGANIC NERVOUS DISEASES. 



659 



he was eighteen months old. He is stated to have had convulsions in his third year, and 
these convulsions occurred again when he was four years old. They were followed hy the 
paralysis for which he has come to the hospital to be treated. He does not use his left hand 
well, and the grasp of the left hand is less strong than that of the right. The triceps 
reflex is exaggerated on both sides. The left foot can with difficulty be flexed dorsally. 
The right knee-jerk is normal, the left is increased. He has flat-foot, and walks with his 
left foot rotated in. He is now six years old, and is otherwise well and strong. 

This is a case of left spastic hemiplegia. 

The treatment in this case is by massage and electricity. Apparatus does not seem to 
be indicated, as its only use is to support the limbs or to correct deformity. 

This boy (Case 300) is four years old. There is a history of phthisis on the maternal 
side. 

Case 299. Case 300. 





Cerebral paralysis. Left spastic hemiplegia, 
two years' duration. Male, 6 years old. 



Cerebral paralysis. Spastic paraplegia. Malt 
4 years old. 



His mother has four other, healthy children, but has a history of three miscarriages. 
This child was born prematurely, and the delivery was instrumental. He has always been 
delicate, and had an attack of measles one year ago. He did not attempt to walk until 
he was three years old, and it was then noticed that he did not use his legs well. He is 
mentally normal. His arms appear to be normal; When placed on the floor he gets up in 
a manner like that which is shown in cases of pseudti-hypertrophic muscular paralysis. 
"When he stands his knees are highly flexed and adducted. He walks on his toes, with a 
tendency to cross the knees. This tendency can be only partially overcome. There is no 



660 PEDIATRICS. 

apparent atrophy of the muscles. The knee-jerks are slightly increased, and there is slight 
ankle- clonus. The skin shows some disturbance of circulation. 

He represents the class of cerebral paralysis which has been designated spastic para- 
plegia, the original cerebral lesion having affected the legs only. 

If this child's condition is not much improved by passive movements of the limbs and 
massage, it may be advisable to resort to operative treatment and divide the tendons of the 
flexor muscles. 

I happen to have here in the wards a case which apparently represents 
the symptoms of traumatic hemorrhage. 

This little girl (Case 801) is four years and nine months old. She was brought to the 
hospital February 28, with a history of having fallen frpm the roof of a three-story building 
upon a brick sidewalk. She was unconscious. She vomited slightly, and she was found to 
have an ecchymosis on the left side of her head. Her pupils were equal and reacted to 
light. Her respirations were rapid ; the extremities were cold. She moved all her limbs 
vigorously. Some clotted blood was found in and about the nostrils. The temperature was 
3j6.3° C. (97.4° F.) ; the pulse was 90, and the respirations were 26. She ground her teeth 
and cried out in the night. The muscles of the left arm and leg moved actively. 

On the next day it was found that she could swallow milk. She passed her urine 
involuntarily. She was still unconscious, and the movements of the left arm and leg con- 
tinued. 

On the following day, for a short time the right pupil was larger than the left, and 
would not react to light. Although she could not speak, her eyes would follow the finger ; 
the eyes also had a restless movement. An enema produced a passage of a small amount 
of faeces and a few drops of blood. The respirations were very deep, and the face was 
flushed. 

On the following day she still continued to move her left arm and leg, while the right 
arm and leg remained passive. The pulse was irregular and intermittent. She was 
reported to have slept more than at any time since the accident, She was still unconscious, 
but was less restless. 

On the next day the pulse was irregular, as it was also two days later. The pupils 
were irregular, and she opened her eyes and fixed them on objects at times. She also 
rolled her eyes and yawned. She was still unconscious. 

Two days later she had slight opisthotonos, and there were spasmodic movements of 
the left arm and leg. She slept a great deal. 

On the following day she appeared brighter, and followed objects with her eyes. Her 
pulse was irregular, from 80 to 90. 

Two days later she seemed brighter, and moved the left arm and leg less. She also 
made voluntary movements, such as to push objects away from her. On this day she 
gave evidence that she understood what was said to her. Three days later she seemed to 
recognize her mother. 

On the following day she began to use her right arm very slightly. She ate a cracker, 
and was at times quite conscious. 

The next day she appeared more intelligent, and on the day after that she began to 
speak single words. It was found, however, that she could move her right arm but very 
slightly. Since this time she has always been perfectly conscious, endeavors to say words, 
and notices the children in the wards, as well as her playthings. 

To-day, — the twenty-ninth day from the time when the accident occurred, — as you see, 
she can walk, though with difficulty, as the right leg is very unsteady. 

She apparently has had a lesion on the left side of the brain, represented by a hemor- 
rhage and caused by traumatism. 

(Subsequent history.) One week later she was discharged from the hospital. At that 
time she could use the right arm fairly well, but walked with some difficulty on account 
of the weakness of the right leg. Her articulation was labored, and her pupils were 
unequal. 



ORGANIC NERVOUS DISEASES. 661 

ATHETOSIS. — Athetosis is a symptom, and not a disease, and is repre- 
sented by continuous incoordinate arhythmical movements of the extrem- 
ities, the face, and the body. This condition may be acquired or congenital. 
The acquired form may follow cases of hemiplegia or diplegia, in which event 
it affects the paralyzed limbs. Certain cases of acquired athetosis occur 
without any accompanying paralysis. In congenital athetosis, and in the 
acquired form without paralysis, the symptoms usually begin in the first 
year. 

Pathology. — The pathological condition which exists in cases of athe- 
tosis is supposed to be a chronic cerebral irritation in the neighborhood 
of the basal ganglia and in the internal capsule. The condition as we 
see it clinically, therefore, is wholly a symptom of some organic lesion of 
the brain. 

Diagnosis. — The diagnosis of acquired athetosis is made by the charac- 
ter of the movements. These are continuous, and are distinguished from 
those of chorea by being vermicular and less spasmodic. 

The diagnosis in cases of congenital athetosis is not difficult, as in no 
other disease does an infant present at birth these peculiar movements and 
this grotesque form of flexion and extension of the fingers and toes. The 
disease called congenital chorea, in which involuntary arhythmical move- 
ments exist, is distinguished from athetosis by the character of the move- 
ments, which resemble those of ordinary chorea. 

Case 302. 




i 



Congenital athetosis. Female, 2 years old. 

Prognosis. — The prognosis of athetosis in regard to recovery is un- 
favorable. So far as the general health is concerned, the individual may 
develop fairly well and may live for years, as in the case of a man, twenty- 
two years old, reported by Bullard. 

Treatment. — There is no known treatment which has proved to be of 
benefit in children. As they grow older the training of the affected limbs 



662 PEDIATRICS. 

may be undertaken, but, as a rule, the results are unsatisfactory. Massage 
and electricity have proved to be of no value. 

I have here a little girl (Case 302, page 661) who represents this con- 
dition of congenital athetosis. 

She is two years old. She has never had any acute disease. She was born after a 
normal labor, and has received no subsequent injury. She has never talked nor shown 
much interest in her surroundings, nor has she been able to sit up or hold up her head with- 
out support. The bowels have always been regular and the appetite good. She is well 
developed, and, as you see, well nourished. 

The disease is characterized by the continual incodrdinate arhythmical movements of 
the head, trunk, and extremities ; these movements are often quite rapid. There is con- 
stant flexion and extension of the hands and fingers, the fingers at times being bent back- 
ward and assuming most grotesque positions. This phenomenon is also seen in the toes. 
The expression of the face, as you see, is not that of ordinary intelligence. I find that I 
cannot determine the reflexes, on account of the resistance of the child to examination. 
She is usually irritable, but occasionally smiles slightly and takes some slight notice of those 
who are near her. 

The prognosis in this case, so far as recovery is concerned, is bad. There seems to be 
no especial reason why she should not live. 

INTRA-CRANIAL TUMORS. — In infancy and early childhood tumors 
of many varieties may occur in the brain and its meninges. The most 
common form of intra-cranial tumor is tubercular. The next in frequency 
are gliomata, sarcomata, and glio-sarcomata. The other varieties, such as 
carcinoma, lipoma, myxoma, and teratoma, are very rare ; and syphilitic 
gummata, which are so frequent in adults, are exceedingly rare in infancy 
and early childhood. The parasitic cysts in the brain which occur quite 
frequently in individuals in other parts of the world, especially in Germany, 
are seldom met with in this country. 

These tumors may be either of intra- or extra-uterine origin. Of these 
the tubercular is the most common. 

Pathology. — The tubercular tumors of the brain or its meninges are, 
as a rule, secondary to a tubercular growth in some other part of the body, 
or to tubercular disease of some part of the skull, such as the orbit or ear. 
These tubercular tumors may be single or multiple, the latter being the more 
common variety. They may be found in any part of the brain or its 
meninges, and occur with especial frequency in the cerebellum. They may 
vary in size from a small collection of miliary tubercle to much larger 
masses. When one or more cheesy masses of a tubercular nature are found 
in different parts of the brain, the condition is called solitary tubercle. The 
gliomata grow most frequently in the w^hite substance of the brain, but 
sometimes develop in the gray matter. According to Starr, they grow less 
rapidly than sarcomata, and never involve the membranes. They are 
usually primary, but may develop as secondary to glioma of the retina 
(Starr). The sarcomata are both of the round-celled and of the spindle- 
celled variety. Although not quite so frequently found as the gliomata, they 
are more frequent than the glio-sarcomata or myxomata. They are usually 



ORGANIC NERVOUS DISEASES. 663 

round in shape, and develop both m the nervous tissue and in the cerebral 
membranes, and in both the white and the gray matter of the cerebrum and 
cerebellum. The other varieties of tumor of the brain are so rare that they 
need not be considered here. 

In connection with intra-cranial tumors, I might mention that intra- 
cranial aneurisms, according to Starr, are rare in childhood and are never 
very large. They increase in size rather more rapidly than aneurisms else- 
where, and show a tendency to rupture. They are found upon the larger 
arteries of the base of the brain and on the Sylvian arteries. The patho- 
logical condition of the brain in the neighborhood of these growths is such 
as would result from the impediment to the blood-current in the small 
vessels, or from compression of some of the larger arterial trunks. The 
condition is usually one of ansemia. The anaemia may be sufficient to im- 
pair the nutrition of the nervous tissue. As a still later pathological con- 
dition in these cases produced by pressure, areas of atrophy of the brain 
may occur. 

Symptoms. — The symptoms which result from intra-cranial tumors are 
very numerous, and are rendered all the more difficult to recognize in in- 
fancy and early childhood by the pronounced nervous phenomena which may 
result from even a slight degree of irritation or pressure in the young and 
undeveloped brain-tissue. 

The general symptoms vary very much in accordance with the size and 
vascularity of the tumor, and according as it is growing or has become sta- 
tionary. In the former case the symptoms are often apt to be more severe 
than later, when, the tumor having become stationary, the brain-tissue adapts 
itself to the new conditions produced by the morbid growth. Intra-cranial 
tumors in infants and in young children are often latent, present no symp- 
toms, and are sometimes discovered only after death. A certain number of 
cases, on the other hand, present only general symptoms, such as headache, 
cerebral vomiting, attacks of vertigo, convulsions, and optic neuritis, which 
cause us to suspect intra-cranial disease, but give an indefinite idea of its 
location. Again, these tumors may produce local symptoms in addition to 
the general ones. These local symptoms are represented by paralyses of 
different kinds, anomalies of sensation, affections of the special senses, and 
staggering. These later symptoms arise according to the site of the tumor 
and the parts of the brain which are affected by it, and by means of them 
we can more or less approximately judge of its situation, size, and rapidity 
of growth. 

I shall not enter here into the various complex questions of brain locali- 
zation, but shall refer you for further information to works especially devoted 
to that subject (Keating's " Cyclopaedia of the Diseases of Children ;" Starr). 
I may, however, say that paralyses of the extremities are caused by an affec- 
tion of the motor cortex, the internal capsule, or any portion of the motor 
tract on the opposite side of the brain above the crossing of the pyramids. 
Staggering or cerebellar ataxia is suggestive of cerebellar disease, while the 



664 PEDIATRICS. 

involvement of the intra-cranial nerves suggests a tumor of the base of the 
brain or pressure on these nerves at some point, and more rarely an aifection 
of their nuclei. The tendon reflexes are apt to be exaggerated, but in some 
cases are normal, and in others are said to be absent. The symptoms of 
cerebellar ataxia which at times occur where the tumor is situated in the 
cerebellum consist of a staggering gait resembling that of an intoxicated 
person, the steps being irregular in length and the body swinging from side 
to side. The child in these cases has a subjective sense of falling or turning 
back, and grasps for support or sinks into a chair or to the floor. This form 
of ataxia is to be distinguished from that which is found in spinal disease, 
and which is due to an inability to coordinate the muscles of the lower 
extremities properly. This latter form of ataxia is much more regular than 
the former, each step being insecure and unsteady, but without the violent 
and sudden reeling, after two or three steady steps, which occurs in the 
cerebellar form. 

In young infants a tumor may cause a protuberance of some part of the 
skull by pushing one of the bones outward, as was seen in a case (Case 303), 
eight months old, of teratoma which was operated upon by Dr. Lovett at 
the City Hospital, and which is one of the few instances of this form of 
tumor on record. 

Diagnosis. — The diagnosis of tumors of the brain must in the great 
majority of cases be made by elimination. The variety of tumor can be 
determined most readily by considering the history of the case, as to 
whether it is tubercular, syphilitic, or otherwise. The diagnosis of a tumor 
can often be made by the slow and gradual development of the disease. 
When severe headache and vomiting exist, followed by paralysis, either 
monoplegic or hemiplegic, especially if this paralysis develops slowly, we 
should suspect the presence of some form of intra-cranial growth. This 
suspicion is much strengthened by the presence of optic neuritis or optic 
atrophy. The presence of localized convulsions in such cases tends to con- 
firm the diagnosis, while if marked ataxia exists we are justified in suspect- 
ing cerebellar disease. A normal or only slightly elevated temperature with 
these symptoms which I have just mentioned also points to the diagnosis of 
a cerebral tumor. 

Prognosis. — The prognosis of tumors in early life is very unfavorable, 
no matter what the variety of the tumor may be. Although the patient 
may for a long time remain wholly unaffected by the morbid growth, he 
eventually, except in rare cases, succumbs to the disease. 

Treatment. — Surgical interference in children, as in adults, proves on 
the whole to be the most valuable means at our command for kingthening 
life in cases of cerebral tumors. There is no other treatment which is of 
any especial benefit in either retarding the growi;h or curing this class of 
cases. Even where the exceedingly rare form of syphilitic gumma exists, 
iodide of potassium and other drugs have not apparently proved to be of 
much value. 



ORGANIC NEEVOUS DISEASES. 665 

In regard to what I have said concerning the latency of tumors of the 
brain, the case which I showed you in the wards some days ago exemplifies 
the extent to which this latency can exist where the tumor is tubercular. 

I have to-day the opportunity of presenting to your inspection the results 
of the autopsy on this case. 

You may remember my telling you when I was examining this infant (Case 304) while 
alive that I could detect nothing abnormal except a moderately raised temperature by 
which I could distinguish it from the case of infantile atrophy in the next bed, which had 
an almost identical temperature and similar symptoms. 

The infant was thirteen months old, had never had any especial disease, and entered the 
hospital weak and emaciated. Its mind was clear. Its pulse was weak but regular, and 
neither slow nor quick for its age. Its temperature was at times somewhat raised, varying 
from 37.2°-38.4° C. (99°-101° F.). There were no convulsions, and no paralysis or con- 
tractures, but merely progressive loss in weight, and finally death. 

An examination of the brain of this infant shows miliary tubercle of the pi a mater at 
the base of the brain without acute inflammation, which accounts for the lack of acute 
cerebral symptoms. Of especial interest, however, in the case are the patches of solitary 
tubercle, 1.2 cm. (J inch) in diameter, which you see in the left temporal and occipital 
lobes and in the right frontal lobe of the cerebrum, and also in the lower left cerebellum. 
There is also caseous tubercle of the post-bronchial glands, tubercle of the lungs with a 
slight amount of broncho-pneumonia, miliary tubercle of the pleura, liver, and spleen, and 
caseous tubercle of the mesenteric glands. 

Through the kindness of Dr. Bullard I am enabled to show you the 
result of the post-mortem examinations in some cases of cerebral tumors 
which have just occurred in his practice. 

A boy (Case 305), four years old, of healthy parentage, but with a history of tubercu- 
losis in his grandmother and an aunt, was perfectly well until he was ten months old. At 
that time he had an attack of general tonic convulsions followed by paralysis of the right 
lower leg. After that the right leg slowly improved, but never entirely recovered. He 
began to walk when he was fourteen months old. After this first attack he remained per- 
fectly well until two months before his death, when he was found to have ptosis and acute 
conjunctivitis on the left side. Three weeks before his death he began to lose in weight 
and to be very sleepy and stupid ; he was feverish and lost the power of walking ; he also 
lost his appetite and his bowels were very constipated. There was no history of his ever 
having had any disease of the ears. 

When examined by Dr. Bullard the head was not retracted, and no tenderness was 
found anywhere over the cranium. "When the left eyelid was raised the eye was found to 
be turned upward and outward. There was some swelling of the eyelids. Both eyes re- 
acted to light. The tongue was protruded straight. The heart and lungs were normal. 
Nothing abnormal was found in the abdomen or spine. There was a flaccid paralysis of the 
right lower extremity, with foot-drop. Nothing abnormal was found in the urine. A few 
days later there was found to be some loss of power in the left upper extremity and left toe- 
drop. The knee-jerks were present. 

He was treated with iodide of potassium, and his general condition improved somewhat. 
The drowsy condition, however, returned, and, although for a time improvement took place 
in regard to the movements of his limbs, he gradually became more stupid, and finally was 
in a torpid condition. He swallowed with great difficulty. He had strabismus of the left 
eye. Nothing abnormal was found in the urine, but it was passed, as well as the fasces, in- 
voluntarily. His temperature varied from 37.2° to 37.7° C. (99° to 100° F.), and his pulse 
was between 80 and 90. 

An examination during the latter part of his life showed that the thoracic, epigastric- 



666 PEDIATRICS. 

cremasteric, and plantar reflexes were excellent ; the triceps reflexes were good. Tlae knee- 
jerks were good, the right less than the left, the latter being exaggerated. Nothing else 
abnormal was detected. 

An examination of the eyes by Dr. Standish, thirteen days before his death, showed 
marked choroiditis in the right eye, with large tortuous veins and arteries nearly obliterated. 
There was indistinctness of outline in the disk in the left eye, with the veins large in pro- 
portion to the size of the arteries. At this time he had deep sighing respirations with 
intervals of a minute or more. 

One week before his death the right arm was rigid at the elbow and the hand and 
fingers were flaccid. At times aii erythema would be seen on his arms and body. Turning 
his head evidently caused pain. The upper part of the head was cyanotic. He was much 
emaciated. The right pupil was much larger than the left, and neither pupil reacted to 
light. The pulse increased in frequency, and at times was between 158 and 160. The abdo- 
men was retracted. He remained in a stupid state until his death. 

The post-mortem examination made by Dr. Bullard showed rigor mortis present in a 
moderate degree. The abdomen was retracted. The head was larger than normal in 
proportion to the size of the body. Nothing else abnormal was noticed on physical exami- 
nation. 

The pleura and pericardium, with their cavities, and the heart were found to be per- 
fectly normal. Behind and to the right of the trachea, at or just above its bifurcation, two 
nodules about 2.5 cm. (1 inch) in diameter were found; they were apparently enlarged 
lymph-glands. On section they were found to be composed of yellowish-white cheesy ma- 
terial. Nothing abnormal was detected in the right lung. In the left lung, about the 
centre of the upper lobe, was a cavity about 2.5 cm. (1 inch) in the longest and 1.2 cm. 
Q inch) in the shortest diameter. This was filled with cheesy material, friable, and easily 
removed. The liver, spleen, intestines, gall-bladder, and bladder presented nothing ab- 
normal. 

On examining the head there was nothing abnormal noticed externally. The longitu- 
dinal and lateral sinuses contained a very small amount of blood, clotted and liquid. The 
dura mater everywhere seemed normal, and was not unusually adherent to the cranium. 
The pia mater seemed normal everywhere except in the neighborhood of the Sylvian artery. 
Here it was more adherent than elsewhere, small pieces of the brain coming away with it 
when it was torn off. Both lateral ventricles were enlarged. 

On the superior surface of the cerebellum there was a projection in the median line of 
part of a mass which occupied the anterior portion of the central lobe. On section it was 
found to be yellowish-green and much firmer than the rest of the cerebellum. Nothing 
else abnormal was detected macroscopically. 

The tumor was examined by Dr. Dunham, who reported that it appeared to have occu- 
pied the anterior middle portions of the cerebellum, and to be about 5 cm. (2 inches) broad, 
3.5 cm, (If inches) from in front backward, and 2.5 cm. (1 inch) from above downward. 
It was circumscribed, and its substance was more consistent than that of the cerebellum. 
It had two globular projections 1.2 cm. (J inch) in diameter, one on each side, extending 
forward, probably one towards each side of the upper part of the fourth ventricle or begin- 
ning of the aqueduct of Sylvius, but not far enough to invade the pons. It did not extend 
farther back than the limits of the quadrate lobes. The cerebellar peduncles were not 
involved. The amygdalae, which were almost directly below and in front of the tumor, 
were not aflected. 

Histologically the tumor was a sarcoma. In parts the structure was gliomatous ; in 
others the cellular elements were so abundant that the microscopic picture was like that 
of a small, round-celled sarcoma. There were many blood-vessels in the substance of the 
tumor. Although the lung was not much affected, several of the peribronchial glands had 
undergone cheesy degeneration. The kidnej^s were small, but their tissues showed nothing 
unusual. Nothing abnormal was found in the other organs. 

There was no evidence of tubercle in the brain or its meninges. 

The next case is that of a little girl (Case 306), eleven years old, a patient at the Chil- 
dren's Hospital. Her parents were healthj^, and there was no history of any disease affect- 



ORGANIC NERVOUS DISEASES. 667 

ing the nervous system in the family on either side. There was no history of phthisis. The 
child was born after a natural labor, with a head presentation, and without the aid of for- 
ceps. When she was eighteen months old she had an attack of pneumonia : she is said 
to have had some "head trouble" at that time, and was never well afterwards. Up to the 
age of six years she had earache, accompanied with a discharge from the ear. According 
to Dr. BuUard, there was some evidence of hydrocephalus at or before this time. She was 
never as strong as other children. She did not walk until she was twenty-seven months 
old, and she was more liable to fall than other children. She was always of a nervous 
temperament, restless, and unable to sleep well. She could never bear any excitement. 
When she was seven years old she had another attack of pneumonia, with a complicating 
pertussis. 

Three years ago she had a severe illness, of which the most prominent symptom was 
pain in the head. This pain was intense in the temples, especially in the left one, and 
she would hold the back of her head with both hands. There was much severe vomiting 
at this time. The temperature was stated to be about normal, and the pulse natural. 
There was also pain in the neck and in all the limbs, but it was slight in the right ex- 
tremities and more severe in the left extremities. This illness lasted ten weeks, and she 
never completely recovered from it. She, however, became well enough to go to school. 

A little later she was found to be blind in the left eye, and three weeks later the right 
eye also became blind. The blindness was supposed to have come on gradually. 

When she was between eight and nine years old she had another very severe illness, 
characterized by pain in the head and vomiting. At this time she was first noticed to have 
momentary "spasms," in which she would scream with pain and would then lose con- 
sciousness, but without convulsions or rigidity. There was no heightening of the tempera- 
ture during this illness. During this attack she could not move any of her limbs. 

A few months later she began to improve, and a month after this was able to walk 
alone. After this there was gradual improvement. 

When she was ten years old the headaches became worse, and she had a third severe 
attack, with vomiting and pain in the head, lasting four weeks. Since that time she has 
not been able to walk alone. 

On entering the hospital she was found to be totally blind. There were paresis and in- 
coordination of both lower extremities. There was considerable incoordination of the left 
hand, while coordination of the right hand seemed normal. There was no atrophy any- 
where. The sensation was unimpaired. The knee-jerks were alike and normal. For two 
weeks she was unable to go to sleep easily, on account of pain and restlessness. While in 
the hospital she would have nausea and vomiting at times, and headache would occur four 
or five times a week, but not so severe as to make her scream. She was unable to walk 
without assistance. When some one held her hand she walked with the feet quite straight, 
striking the ground first with the heels, and tilting the pelvis more than normal. Her 
appetite was good. At times she would have constipation, followed by diarrhoea, with in- 
voluntary dejections. The vomiting and headache continued. While she was in the hos- 
pital she was for a time quite comfortable. Her temperature ranged from 36.9° to 37.7° C. 
(98.5° to 100° r.). There were no other symptoms worthy of note. Examination of the 
urine showed it to be normal. 

After leaving the hospital, when she was eleven years old, she had less headache for a 
short time, but then became worse. She had several severe attacks, reported by the fiunily 
as " fainting-spells," in which there was loss of consciousness without convulsions, and she 
died quietly in one of these to-day. 

I have here the result of the examination of the head and a statement of the patho- 
logical conditions which were found. 

On removal of the external tissues the cranium presented a translucent appearance, 
suggesting extreme thinness of the cranial bones, and large white bands 2.5 cm. to 3.7 cm. (1 
to 1^ inches) broad lay in the position of the larger cranial sutures, as though these sutures 
had long been held open by intra-cranial pressure. The bones of the cranium were unusually 
thin, those forming the calvaria being not much more than 0.6 cm. {\ inch) in thickness. 
The calvaria was very elastic, could be readily compressed, and when the pressure was 



668 PEDIATRICS. 

removed would spring back to its original shape with much force. The inner and outer 
tables were thin and very hard, while the diploe seemed disproportionately large. The dura 
mater was adherent along the coronal sutures, but was otherwise normally free. Its blood- 
vessels were rather injected. The longitudinal sinus was empty. The pia mater showed 
nothing abnormal, except that its blood-vessels were somewhat injected. A large quantity 
of clear, pale-yellowish fluid, estimated at about 1440 c.c. (3 pints), escaped from the cere- 
bral ventricles on removal of the brain. The third ventricle was much dilated, and formed 
a cyst-like projection at the base of the cerebrum. The lateral ventricles were greatly 
dilated, each occupying almost the whole of the corresponding hemisphere, the white sub- 
stance and the cortex between them being much thinned. There were no hemorrhages, 
cysts, or other peculiarities detected in the cerebrum. 

On inspection of the cerebrum, a gelatinous mass of rounded lobular shape, suggesting 
a cyst, was seen projecting from the external surface of the left lobe. On palpation this 
was found to contain fluid, and to be connected with a hard mass occupying this lobe. 
This mass was examined by Dr. Mallory, who reports that the cyst which I have just men- 
tioned was emptied and collapsed. On section vertically through the centre of the left 
lobe of the cerebellum, extreme resistance was met with, such as would suggest bone or 
cartilage. The section showed a globular cavity 3.7 cm. (1| inches) in diameter, containing 
a thick, greenish-yellow, semi-fluid mass, resembling pus, and surrounded by a circular 
border, 3.7 cm. (1^ inches) broad, of a yellowish- white color with a slight bluish tinge, 
largely composed of circular masses like sago-grains, separated from each other by tissue 
of nearly the same color as themselves. These circular masses gave a peculiar translucent 
appearance to this border or capsule. The tumor occupied the larger portion of the left 
lobe of the cerebellum and its whole outer two-thirds. 

The report of the microscopic examination made by Professor Councilman is as 
follows : 

The tumor is not so sharply circumscribed as the macroscopic appearances would 
indicate. The structure of the tumor itself is somewhat complex. It consists of a variety 
of cells, the prevailing type being similar to those of round-celled sarcomata. This is 
especially seen in the portions of the tumor apparently the freshest and of most rapid 
growth. In some places the cells are rather irregular in size, with numerous processes 
similar to the spider-cells of the brain. The principal extension of the tumor is along the 
lymph-sheaths of the vessels. These are filled with round cells, in many places at a con- 
siderable distance from the main body of the tumor. There is more or less tissue between 
the cells, consisting in part of a regular formation of close connective tissue and in part of a 
very loose reticular tissue. Throughout the tumor there are numerous foci of degenera- 
tion, the largest of which correspond to the circular masses described by Dr. Mallory. In 
numerous places in the tumor there is an entire infiltration with pus-cells. One of the 
chief characteristics of the tumor is the hyaline degeneration both of the cells and of the 
blood-vessels. Large masses of a perfectly homogeneous material giving all the reactions 
of hyaline are found both in and along the course of the blood-vessels in various parts of 
the tumor. From the size and position of many of these hyaline masses it is evident that 
cells also have taken part in their formation. 

The tumor is to be regarded as a glio-sarcoma, with hyaline degeneration of the blood- 
vessels, and foci of necrosis. 

INTRA-CRANIAL SYPHILIS.— Intra-cranial syphilis may be either 
congenital or acquired. According to Bullard, the intra-cranial lesions are 
essentially the same in both forms. 

Pathology. — Intra-cranial syphilis may be divided pathologically into 
three forms : (1) diffuse inflammation of the meninges or their neighboring 
tissues, (2) localized growths or tumors (gummata), and (3) syphilitic endar- 
teritis. In the latter case (endarteritis) there may be local dilatation or local 
occlusion of the blood-vessels. These conditions are apt to occur simulta- 



ORGAXIC XERYOUS DISEASES. 669 

neoiisly. When the dilatation reaches an advanced stage a thinning of the 
arterial walls results^ which may lead to rupture of the blood-vessels or to 
hemorrhage. More common than the hemorrhage, however, is the occlusion 
of the blood-vessels, which cuts off the blood-supply and acts in the same 
way as in other cases of thrombosis of the arteries, causing more or less 
softening and disintegration of the cerebral tissues supplied by them. The 
arteries of the base of the brain are the ones that are most fi^equently 
affected, and there are secondary lesions of the parts of the brain supplied 
by them. 

Symptoms. — The symptoms dependent on these lesions vary in accord- 
ance with the pathological condition. 

In syphilitic meningitis the principal symptoms are severe headache in 
various parts of the head, more or less constant, lasting for many days or 
even weeks, and frequently accompanied after a time by paralysis of some 
of the intra-cranial nerves, especially of the third or of the seventh. As in 
other cases of meningitis, the optic nerves may also be affected, and the child 
shows the general symptoms of a severe intra-cranial affection, such as 
vomiting and dulness. 

The localized tumors or gummata present essentially the same symptoms 
as do the other forms of tumors of the brain in children which I have just 
described. 

The symptoms produced by syphilitic endarteritis are the du^ect result 
of either the local dilatation or the local occlusion of the blood-vessels, 
which I have just mentioned. The symptoms vary according to the areas 
of the brain affected, but the most common ones are the various forms of 
paralysis of the extremities and sensory disturbances. 

Diagnosis. — In regard to the diagnosis of intra-cranial syphilis in 
children, the symptoms differ greatly in different cases. The most charac- 
teristic group of symptoms, and one which is exceedingly suggestive of 
intra-cranial syphilis, includes attacks of organic paralysis, central in origin, 
occurring at intervals of days or months without known cause, and without 
marked symptoms of either tumor or tuberculosis. 

The diagnosis of cerebral meningitis may be made from the occurrence of 
severe headaches, followed by paralysis of one or more of the motor cranial 
nerves, and occm-ring without marked rise of temperature. 

Gimimata present no symptoms sufficient in themselves to distinguish 
them from other intra-cranial tumors, so that their existence can only be 
suspected. 

The presence of syphilitic lesions elsewhere is our principal groimd for 
making the diagnosis. 

Syphilitic endarteritis may be suspected when an acute affection in the 
neighborhood of the pons or medulla not produced by traumatism occurs 
in a syphilitic subject, or where acute symptoms suggestive of hemorrhage 
or embolism occur, and where no other probable cause can be shown, such 
as cardiac or renal disease. 



670 PEDIATRICS. 

Prognosis. — The prognosis of intra-cranial syphilis is said to be moder- 
ately favorable. The early stages of syphilitic meningitis, and sometimes 
even gummata, may be favorably inflnenced, or even cnred. Of this, how- 
ever, we have no decided proof, and in the more advanced cases, or where 
endarteritis exists, the prognosis is unfavorable, as no known remedies appear 
to have mnch influence on the secondary changes in the arteries. 

Treatment. — The treatment should be with large doses of iodide of 
potassium, usually combined in the beginning with mercury. For a child 
two or three years old the initial dose of the iodide may be 0.3 gramme (5 
grains) three times daily, gradually increased to 0.6 gramme (10 grains) 
unless gastric disturbance occurs. 

IDIOCY. — By the term idiocy is meant a condition of marked mental 
deficiency. This mental deficiency may be of different grades. 

Pathology. — Idiocy is, as a rule, the result of imperfect or impeded 
brain development, or it may be caused by actual destruction of portions 
of the brain. This condition may be produced by (1) traumatism, (2) non- 
traumatic inflammation, and (3) mechanical pressure. 

(1) Traumatism acts usually by causing hemorrhage or destruction of the 
cerebral tissue in other ways. 

(2) The most common form of inflammation causing idiocy is a more or 
less diffuse encephalitis, which ends in sclerosis and meningo-encephalitis. 

(3) Hydrocephalus appears to cause or to accompany certain cases of 
idiocy. In some of these cases the distended ventricles cause atrophy of 
the cerebral tissue by pressure, while probably the distention of the ven- 
tricles is sometimes secondary. How far the degenerative conditions are 
primary and how far they follow pre-existing inflammations is at present 
unsettled. 

The result of these pathological conditions is usually atrophy. This 
atrophy may be of intra- or extra-uterine origin, and may be local or 
general. 

Symptoms. — The symptoms of idiocy vary according as the individual 
represents a high or a low grade of this condition. An idiot may have a 
large head from hydrocephalus, or he may have a small head from cere- 
bral non-development or from cerebral atrophy. Again, idiots may have 
normally developed crania both as to size and as to shape. In the lower 
grades there is often some physical malformation in connection with the 
mental impairment. In the more severe cases of idiocy there is consider- 
able incoordination of the limbs, and the movements of the child are awk- 
ward and irregular. In many cases the speech is almost unintelligible. 
The idiot does not take notice of surrounding objects as does the normal 
child, and even w^hen the sight and hearing are perfectly normal the impres- 
sions made on the senses are deadened. Epileptiform convulsions very 
commonly accompany idiocy, and play a most important part in the general 
condition of the patient. 

The symptoms which are usually met with, and which enable us to 



ORGANIC XERVOUS DISEASES. 671 

diagnosticate a pronounced case of idiocy, are the vacant expression, the 
occasional presence of strabismus, the drooping head, the drooling, and the 
lack of all idea of cleanliness. The teeth are usually decayed. Sometimes 
the child is so limp that he is unable to bear his weight at all, or will stand 
held by his parentis hands, with his feet far apart, his knees bent, and his 
trunk leaning forward. The whole body sways to and fro with an oscil- 
lating movement and absence of equilibrium. When able to walk alone he 
walks in a staggering, uncertain way, and falls easily. In many cases, 
however, the child cannot even sit up alone. The muscles of the neck are 
often so weak that the head falls over on one shoulder or forward on his 
chest. The vertebral column fails to support the trunk and bends to a 
marked degree, and all the muscles are feeble and comparatively useless. 
Lack of the power of attention and lack of memory exist in all cases, and 
in the higher grades are often the most prominent symptoms. 

Diagnosis. — We should be careful in very yonng children not to con- 
fuse slow or retarded mental development with idiocy. There is so much 
variation in the time at which children walk and talk, that a delayed de- 
velopment of these functions must not be considered to represent a con- 
dition of mental impairment. Some children develop so slowly, both bodily 
and mentally, that they appear very backward in comparison with others of 
the same age. Children in the first year of their lives may be so seriously 
affected by some grave disease that their development is prevented from 
advancing normally, and in comparison with other children of the same age 
they may be far below the usual grade of intelligence. If, however, we 
examine this class of cases carefully, we see that, although they are very 
backward in their development, they are gradually developing, and that 
they do not represent the condition of complete arrest of development which 
exists in idiots. 

It is well to remember that in rhachitis we are apt to have not only 
retarded mental development but a weakness of the extremities simulating 
paralysis. When both these conditions occur, such cases may sometimes be 
mistaken for idiots. 

Treatment. — The treatment of idiots is essentially comprised under 
the question of their education. The education of this class of cases should 
be begun early, usually from the fourth to the sixth year. Much can be 
done to improve the various defects which exist in each individual. He can 
usually be taught to coordinate his movements, and by attending to his 
general health his physical condition can often be much improved. In 
many cases if convulsions are present they can be more or less controlled. 
Malformations or paralyses can be treated with benefit by apparatus or by 
operation. The best results in these cases will be attained by placing the 
children in institutions devoted to the training of idiots. Parents can be 
told that the association of their children with others who are feeble-minded 
is not a disadvantage , while it is often a g-reat disadvanta2:e for the children 
of sound mind in a family to be associated with one who is idiotic. In the 



672 



PEDIATRICS. 



large majority of cases, however, they will always have to be supervised 
during their lives, and, in most instances, after they have advanced to a 
certain point they are liable to retrograde. 

I have here a feeble-minded or idiotic child (Case 307), three years old. 

I shall first call your attention to the child's peculiar vacant expression, and to the fact 
that it behaves more like an infant than like a child. Its mental does not correspond to its 
physical development, for it is able to walk and to use its arms and hands freely. This child, 
however, was not able to support its head alone during the first year of its life, and did not 
learn to walk until very lately. You see that there is no especially unnatural shape to its 
head, which has the circumference which would be normal for a child of this age. 

Case 307. 




Idiocy. 

This child presents the usual variations in temper which are so common in idiots. In 
the very severe grades the temper is apt to be happy and quiet, while in this grade, where 
the physical development has not been so much interfered with, we find that explosions of 
temper are quite frequent. The child is not able to feed itself, and, although it will proba- 
bly develop into an individual of fair strength, we can have but little hope of any improve- 
ment in its mental condition. You will notice that it drools continuously. 



I shall not attempt to describe the various forms of idiocy, such as are 
produced by hydrocephalus, cretinism, epilepsy, syphilis, acute febrile dis- 
eases, traumata, and other causes, but shall simply mention a peculiar class 
which is represented by microcephalus. 

MiCROCEPHALUS. — When the head is under a certain size it is called 
microcephalic. The size which is usually accepted as representing a micro- 



ORGANIC NERVOUS DISEASES. 673 

cephalic head is from 40.5 to 43 cm. (16 to 17 inches). According to Broca, 
microcephalus exists where the brain weighs 1049 grammes (35 ounces) in 
the male, and 907 grammes (30 ounces) in the female. It is generally con- 
sidered that this microcephalic condition is due to a lack of intra-cranial 
pressure. Together with the lack of development of the cranial bones 
there exists in these cases a lack of development or atrophy of the brain, 
which may be considered either as the cause of the lack of intra-cranial 
pressure or, as is still believed by some writers, as the result of the external 
pressure caused by a premature synostosis. Microcephalic children are 
feeble-minded and usually present the symptoms of a somewhat low grade 
of idiocy. They not infrequently show signs of want of power of the 
limbs. This child which I have here is an instance of this kind. 

She (Case 308) is three and a half years old, and is the eldest of three children. Her 
parents are healthy, as are the other children. She has never spoken. She can feed her- 
self, and she walked when she was two and a half years old. She has incontinence of 
urine. She has never learned anything, has a violent temper, and sometimes has nervous 
attacks, which are prohahly of an epileptiform nature. The cranium is normal in shape, 
except that the forehead is very narrow, with a median vertical broad ridge. The fonta- 
nelles are closed and show no depression. There are no marked prominences about the 
skull. She is decidedly feeble-minded, and her attention cannot be attracted or fixed 
readily. The eyes are apparently normal, and her teeth are in good condition. There is 
a condition of paresis and incoordination, but the sensation is normal. The chest measures 
49.5 cm. (19J inches), and the head 43 cm. (17 inches). 

I show her to you merely on account of the small size of the head in comparison with 
the hydrocephalic heads of which I have already spoken. 

MIRROR WRITING-. — An unusual and somewhat striking symptom 
which at times occurs in severe and, as a rule, chronic cerebral disease is 
one which is called "mirror writing." This symptom is usually found 
where there is cerebral degeneration or among the feeble-minded. The 
actual pathology of the affection has not yet been determined. Through 
the kindness of Dr. Acker, of Washington, I am enabled to describe to 
you two cases (Cases 309, 310) of this kind which I had an opportunity 
of examining with him, and I shall quote freely from what he said after 
carefully studying these cases. 

The condition, represented by cases of this kind is designated " mirror 
writing'' because the individual writes in such a way that the letters can 
be deciphered only when they are reflected in a mirror, when they assume 
the appearance of ordinary writing. These specimens of writing are similar 
to those which appear on blotting-paper on which the impression of an 
ordinary specimen of writing has been taken. The affection is usually 
found among left-handed children and in adults after right-handed paralysis. 
There seems to be a physiological tendency for left-handed chiklren to fall 
into the habit of " mirror writing." The tendency of the left hand to write 
in this way is, according to Erlenmeyer, due to the fact that it is easier to 
use the arms in a centrifugal direction, the left from the right and the right 
from the left. Leonardo da Yinci was a noticeable example of this atfec- 

43 



674 PEDIATRICS. 

tion. The earliest recorded case of "mirror writing'^ was in 1688, in an 
epileptic girl twenty-one years of age. 

Dr. Acker's first case (Case 309) was a mulatto boy, ten years of age. He was born 
prematurely at about tbe eighth month. His father is a nervous man, and does not talk 
plainly, but is well educated. His mother has tuberculosis of the lungs. One maternal 
uncle was insane. 

For the first few weeks of his life he was in a very feeble condition, but finally he became 
healthy and strong. Whenever he was slightly sick he would have convulsions. When he 
Avas two and a half years old he fell a distance of 420 cm. (14 feet) upon a bed of concrete. 
A deep wound in the frontal region was caused by the accident, but there was no fracture. 
He did not lose consciousness, and immediately after the fall responded intelligently to any 
questions that were put to him, but he did not cry even when the stitches were put in the 
cut. From the time of the accident the convulsions became more severe and more frequent. 
Three years ago he began to have chorea. His intelligence is about the same as that of the 
average child. At one time it seemed as though he would develop into a kleptomaniac, but 
at present he shows this disposition at intervals only. He is of a mild and docile tempera- 
ment, has very little to say, and responds usually by a nod of the head. He is naturally 
left-handed, and his first attempts at writing resulted in this form of mirror writing. He 
has also been taught to use his right hand, and he now writes with equal dexterity in two 
ways with each hand. 

Fig. 96. 

Mirror writing of a boy 10 years old. 

• 

Here is a specimen (Fig. 96) of this boy's writing, and if you will hold it in front of 
the mirror you will see that it represents a child's writing, the upper line being " All nature 
languid seems and sad." 

The next case (Case 310) was a colored boy, nine years old. His father and mother 
were healthy, but of a low order of intelligence. He had two sisters who were fairly intel- 
ligent, and a brother eighteen years old who was idiotic. The boy himself was not bright, 
and his mother could not trust him away from home. He did not talk plainly. He had 




ORGANIC NERVOUS DISEASES. 675 

convulsions during the first year cf his life, but was considered to be in fair health. He had 
always been left-handed, and writes " mirror writing" only. 

Fig. 97. 













Mirror writing of a boy 9 years old. 

Here is a specimen (Fig. 97) which represents some very poor writing of this boy'i 
The upper lines are " Monkeys live in the forests in warm countries." 



676 PEDIATEICS. 



IvKCTURK XXXII. 

CORD. 

Myelitis. — Poliomyelitis Anterior. — Paralysis caused by Caries of the 
Spine.— Hereditary Ataxia (Friedreich's Disease). — Locomotor Ataxia. — 
Syringomyelia. 

MYELITIS. — The term myelitis denotes an inflammation of the spinal 
cord, whether of the gray or of the white matter. Acute myelitis has been 
used to designate an acute diffuse inflammation of both the gray and the 
white matter of the cord of non-traumatic origin, and is an affection almost 
unknown in children. Considerable confusion still exists in regard to the 
use of the term transverse myelitis, which from its derivation should be 
employed to designate an inflammation of the spinal cord extending trans- 
versely over the greater portion of a section of the cord. This term has, 
however, been employed to denote the results arising from compression of 
the cord, whether from injury or from caries or from tumor, although in 
these cases there exists considerable doubt as to whether any true inflamma- 
tion exists. I shall therefore discard the term transverse myelitis. 

The term meningo-myelitis is used to denote an inflammation of the 
meninges and of the spinal cord. 

As acute myelitis, meningo-myelitis, and hemorrhage into the cord are 
extremely rare in early life, it does not come within my province to dis- 
cuss them. I shall therefore begin by speaking of the form of myelitis 
represented by poliomyelitis anterior. 

POLIOMYELITIS ANTERIOR.— The most frequent and therefore 
the most important disease which affects the spinal cord with a resulting 
paralysis in infancy and early childhood is called poliomyelitis anterior. 
This disease occurs most commonly in the first three years of life. It is rare 
in the first six months of life. It may occur in later childhood, and, very 
rarely, in adults. It is met with more commonly than cerebral paralysis. 

The disease may be primary, in which case it is without any known 
cause ; or it may be apparently secondary to other diseases, such as the acute 
exanthemata and erysipelas. Traumatism appears to be occasionally a cause 
of the disease. Most of the cases occur during the summer months. 

Pathology. — The pathological condition which occurs in poliomyelitis 
anterior is now considered to be an acute inflammation of the cells of the 
anterior cornua of the spinal cord, with a resulting degeneration and atrophy 
of these cells. This condition may be confined to the anterior cornua, but 
in some cases it may involve the spinal meninges somewhat. So few post- 
mortem examinations of the early lesions connected with this disease have 
been made that we are dependent for om- knowledge of it mostly on cases 



ORGANIC NERVOUS DISEASES. 677 

which have been examined a number of months or years after the produc- 
tion of the initial lesion. These later pathological conditions are, however, 
quite characteristic. The circumference of the limb grows small in com- 
parison with that of the opposite one, the result of an active muscular 
wasting and of retarded growth. The bones of the affected limbs are often 
shorter than those of the other side, sometimes even to the extent of several 
inches. In certain cases, however, the lengths of the bones seem to be but 
little affected, though the atrophy of the muscles may be very marked. The 
anterior cornua of the region affected, which is usually in either the cervical 
or the lumbar enlargement, are found to be greatly atrophied and many of 
the large motor cells to have been destroyed. According to Osier, the 
affected half of the cord may be considerably smaller than the other, and 
the anterior lateral column may show slight sclerotic changes, chiefly in the 
pyramidal tract. Accompanying this condition the corresponding anterior 
nerve-roots are found to be atrophied, and the muscles connected with the 
region of the cord which is affected atrophy and gradually undergo a fatty 
and sclerotic change. 

Symptoms. — The onset of the disease in the great majority of cases is 
acute. Its course is chronic. In the acute form the onset may be preceded 
for some days by fever and restlessness, but it is very apt to appear sud- 
denly, with, at times, convulsions which, as a rule, are of a milder type than 
those which occur in cerebral paralysis. 

In addition to the cases which are manifestly acute in their origin there 
have been mentioned certain subacute and chronic cases. There is some 
doubt, however, whether these cases do not originate in the same manner as 
those which are called acute. The probability is that in most of the cases 
which appear not to have had an acute onset and in which the paralysis 
seems to develop slowly, the early acute onset has been overlooked. This 
subacute variety of poliomyelitis anterior does not differ from the acute cases 
in any way in its symptoms, prognosis, diagnosis, and treatment. " 

Following the acute onset there are at times unconsciousness, lasting 
sometimes for a number of days, vomiting, general nervous disturbance of 
the bladder and intestines, and a variety of symptoms of nervous irritability 
which may represent the prodromata of a number of diseases. The temper- 
ature is seldom very high, 38.3° to 38.7° C. (101° to 102° F.) ; it may, how- 
ever, in certain cases be higher. At times there are no prodromata, but the 
paralysis is noticed in the morning after a night^s rest, although on the 
evening before the child was seemingly perfectly well. The severity and 
length of the prodromal symptoms are no indications of the gravity of the 
lesion or of the prognosis as to recovery. Pain in the paralyzed limb is not 
an uncommon symptom, but occurs only very early in the disease. Tlie 
disease is primarily a motor disturbance, sensation remaining intact. Cere- 
bral symptoms, if present, pass off rapidly with the appearance of the paral- 
ysis. The paralysis is usually apt to affect more than one limb in the begin- 
ning, but, as a rule, soon becomes monoplegic. The leg is more frequently 



678 PEDIATRICS. 

aifected than the arm. Paraplegia in the beginning is not uncommon, and 
all forms of paralysis may occur. There may also be diplegia, cross pa- 
ralysis, the affection of both arms, and paralysis of the muscles of the back 
and abdomen. Hemiplegia, so common and almost characteristic of cerebral 
paralysis, may be present, but is rare in poliomyelitis anterior. The muscles 
most frequently affected are the extensors, adductors, and supinators. The 
distribution of the paralysis is usually in groups of muscles. The respira- 
tory muscles may be affected, though rarely. Facial paralysis is so rare 
that it can almost be said never to occur in uncomplicated poliomyelitis. 
When the prodromal symptoms have passed off, as they usually do very 
quickly, the functions of the child are carried on as usual, and the general 
growth and mental activity are unimpaired. The tendon reflexes disappear 
in the affected limbs. When the paralysis has reached its height it remains 
stationary for perhaps from three to six weeks, and then gradual improve- 
ment begins, and goes on in certain groups of the paralyzed muscles for six 
or eight months, leaving other groups paralyzed. These groups again at 
times recover entirely or remain disorganized, and thus lead later to con- 
tractures and deformities. When contractures occur they appear later than 
do those of cerebral origin. These contractures are to be distinguished from 
those of cerebral paralysis, which are always spastic, while those of spinal 
origin are paralytic. 

When paralysis affects wholly or chiefly the gastrocnemii and posterior 
tibial muscles, the other groups act predominantly, causing dorsal flexion of 
the foot, so that the child walks on its heel. This condition is termed tali- 
pes calcaneus. When, on the other hand, the tibialis anticus and anterior 
muscles of the leg are most affected, the deformity of talipes equinus occurs ; 
and if the peronei muscles remain unaffected, there is valgus, while if they 
are affected with the anterior group, talipes equinus varus occurs. Disloca- 
tion of the hip may occur in certain cases of complete paralysis of the leg. 
Severe cases may show complete fiaccidity, and not unfrequently the liga- 
ments about the joints are so weakened that the joints become too movable, 
and the condition called flail-joint results. This condition may be present 
at the hip, knee, or ankle, and sometimes at the shoulder or wrist. Marked 
atrophy appears in a few weeks. Muscular atrophy, rapid and extreme, is 
the rule in poliomyelitis anterior. Shortening of the bones from arrest of 
growth may also appear. The surface temperature of the affected limb is 
lowered, the limb feels cold, relaxed, and lifeless, and the circulation is 
generally sluggish. Spasmodic movements, except the primary convulsions, 
are absent. 

Diagnosis. — In the stage of onset, and until paralysis has appeared, the 
diagnosis must be held in abeyance. The salient points by which a diagno- 
sis can usually be made are (1) sudden paralysis ; (2) loss of tendon reflex ; 
(3) rapid atrophy ; (4) cold, flaccid limbs ; (5) absence of impairment of 
sensation; (6) presence of the reaction of degeneration and a diminished 
reaction to the faradic current. 



ORGANIC NERVOUS DISEASES. 



679 



It is always difficult to diagnosticate poliomyelitis in the initial stage of 
the disease. At that time pain and sensitiveness of the affected limb may 
be present^ and may lead us to suspect that the disease is rheumatism. The 
convulsions and unconsciousness which may appear at this stage are so 
often present in other diseases that they are not of much aid in making the 
diagnosis of poliomyelitis anterior. 

The most reliable test at our command for making the diagnosis of 
poliomyelitis anterior is the electrical reaction, and when this can be obtained 
it clearly characterizes the disease. The normal muscles react to both the 
faradic and the galvanic current. In applying the galvanic current a quick 
muscular contraction is noticed both on the opening and on the closing 
of the negative (cathodal) and of the positive (anodal) pole, but is greater 
when the cathodal pole is closed. When the galvanic current is applied 
to the muscles affected by poliomyelitis anterior, the contractions continue, 
but are slower and less sharp, and the reverse of what takes place in normal 
muscles occurs. Thus, the anodal closure causes a contraction equal to 
or greater than that caused by the cathodal closure (reaction of degener- 
ation). As the muscles recover there is first a return to the normal galvanic 
reaction and later to their normal faradic excitability. The diagnosis in 
young children, however, by means of the galvanic current is practically 
useless except in the hands of an expert. The faradic excitability begins to 
diminish within a few days after the onset of the paralysis, and disappears 
entirely from those muscles which are severely affected. 

Differential Diagnosis. — Poliomyelitis anterior is most apt to be 
mistaken for cerebral paralysis, and can be best differentiated from that 
disease by means of the symptoms which I have already described, and 
which are represented in this table (Table 104). 

TABLE 104. 





Cerebral Paralysis. 


Poliomyelitis Anterior. 


Pathology 


Hemorrhage. Embolus. 
Thrombosis. Sclerosis. 
Atrophy. Porencephalia. 


Inflammation of anterior cor- 
nua of cord. 


Age 


Under three years. 


Under three years. 


Onset 


Acute febrile. 


Acute febrile. 


Motor disturbance .... 


Paralysis. Most common form 

hemiplegia. 
Spastic rigndity. 
Spastic gait. 
All the muscles of a limb 

affected. 


Paralysis. Most common form 
monoplegia. 

Ehiccid. 

Groups of muscles in a limb 
aftected, usually the exten- 
sors. 


Contractures 


Of all the muscles, especially 
the flexors and adductors. 


Of the flexors in the calf 



680 



PEDIATRICS. 
TABLE 104:.— Continued. 





Cerebral Paralysis. 


Poliomyelitis Anterior. 


Spasmodic movements 


Athetosis. 

Post-paralytic chorea. 
Epileptiform convulsions. 


Absent. 

Convulsions may occur at the 

onset of the disease. 


Sensation . 


Unaifected. 


Unaffected. 


Nutrition 


Arrest of growth. 


Tendency to extreme atrophy 
coming on early in the para- 
lyzed limb. 


Electrical reaction . . . 


Normal. 


Keaction of degeneration. 


Tendon reflex 


Exaggerated on the paralyzed 
side. 


Absent. 


Speech 


Liable to be impaired. 


Unimpaired. 


Intelligence 


Often impaired. 


Normal. 



Other affections which may be mistaken for poliomyelitis anterior are 
(1) the paralysis following multiple neuritis; (2) progressive muscular 
atrophy ; (3) pseudo-hypertrophic muscular paralysis ; (4) rhachitic pseudo- 
paralysis ; (5) scorbutus. 

(1) The principal points by which multiple neuritis is to be distinguished 
from poliomyelitis anterior are (a) the symmetrical affection of the limbs in 
the former and tenderness over the nerve-trunks ; (6) the atrophy in mul- 
tiple neuritis is not so severe as in cases of poliomyelitis anterior ; (c) the 
course of the disease is different, cases of multiple neuritis almost invariably 
recovering, while severe cases of poliomyelitis do not recover. 

(2) Progressive muscular atrophy, to which I shall refer in a later 
lecture (page 763), is so rare an affection among children that it need only 
be alluded to. There have been a few cases, however, where this disease 
began in children in the legs, and the paralysis is to be distinguished from 
that of poliomyelitis by its gradual onset, by the galvanic reaction con- 
tinuing normal, and by the faradic excitability usually remaining as long as 
there is any muscular substance left. In this disease, also, the reflexes are 
not lost until the muscular substance has disappeared. 

(3) Pseudo-hypertrophic muscular paralysis in its early stage is not 
likely to be mistaken for poliomyelitis, for the absence of abnormal elec- 
trical reaction, the increase in the size of the muscles, and its gradual 
onset are distinguishing points ; although in the ' later stages of this disease 
atrophy may occur, the history will then clearly differentiate the condition 
from poliomyelitis. 

(4) In certain cases of rhachitis the power of using the legs is so much 
affected that the mistake is quite commonly made of supposing that these 



ORGANIC NERVOUS DISEASES. 681 

children are affected by poliomyelitis anterior. The condition in rhachitic 
children is one of weakness and not of paralysis, and can be distinguished 
by the normal electrical reaction of the muscles and the lack of pronounced 
atrophy. 

(5) The pseudo-paralysis which is commonly seen in cases of scor- 
butus is often mistaken for some organic disease of the central nervous 
system, with its resulting paralysis. The differential diagnosis from polio- 
myelitis anterior, however, is not difficult to make, for the involvement 
of other joints in addition to those of the legs, the presence of pain 
and tenderness to such a degree that the child cries whenever the limbs are 
touched, and the normal temperature of the skin clearly distinguish this 
condition from poliomyelitis, in which disease normal sensation, freedom 
from pain, and a cold feeling of the limb affected are found. 

Prognosis. — So far as a fatal issue is concerned, the prognosis is very 
favorable. If death occurs it usually takes place at the end of one or two 
weeks, and is the result of interference with respiration, which may be caused 
where the paralysis is extensive. Where in the initial stage of the attack 
cerebral symptoms are prominent and continue for some time, the prognosis 
is grave. 

A second attack of the disease is very rare, and when it occurs it usually 
comes a few days after the original attack, and manifests itself by an in- 
crease of the existing paralysis. The paralysis, as a rule, will not increase 
when it has been stationary for twenty-four hours. The tendency of 
poliomyelitis is for a time to improve. Some of the limbs affected recover 
in the first few days, but in those which remain affected longer perfect 
recovery is rare. When there is no improvement after six or eight months 
the probability is that entire recovery will never take place, though under 
proper treatment a slight improvement may go on for years. 

We must remember that, even when untreated, a case of poliomyelitis is 
very apt to improve for one or two months quite rapidly, then rather slowly 
for two or three months, and then, after a stationary period, contractions, 
looseness of the joints, and malpositions may begin to be evident and may 
increase indefinitely. 

When proper treatment is carried out, the prognosis is much more favor- 
able, and the period of possible improvement can be extended for some 
years. According to Bradford and Lovett, there is certainly no leg, how- 
ever wasted and contracted, that is not amenable to some improvement by 
operative or mechanical treatment. 

Treatment. — The treatment of poliomyelitis by means of drugs has 
produced such unsatisfactory results that it may be said to be useless. The 
very multiplicity of the remedies which have been experimented with proves 
their inefficiency. It is doubtful whether any treatment by drugs can be 
beneficial to a central lesion of this character. Although a number of reme- 
dies have been recommended to be given in the onset of the attack, it is 
probable that none of them are of any especial benefit ; though it is wise to 



682 PEDIATRICS. 

see that the bowels are freely moved, and, if the attack has been ushered in 
by convulsions, to treat these symptomatically if they continue. 

Although we know of no rational means of treating the primary lesion 
of poliomyelitis anterior, we know that the results of this lesion, as shown 
by paralysis of the muscles, are such that the paralysis should be treated at 
once. The indication is to combat the rapid atrophy w^hich is part of the 
disease, and to prevent its increase, and its later results from proceeding to 
a degree which would interfere with subsequent repair. To accomplish this, 
the affected limb should be supported in a normal position and carefully 
guarded against the stretching of joints, ligaments, and muscles. In addi- 
tion to this, gentle massage and the faradic current applied five or ten 
minutes at a time at least four or five times a week are indicated to keep 
the affected muscles in the best possible condition and to combat the atrophy 
which to a greater or less degree occurs. The regular application of heat 
is also found to be useful where the limb is cold. According to Bradford 
and Lovett, muscles are much less likely to contract and deformities thus less 
apt to result in properly supported limbs. 

The later manifestations of club-foot and other deformities should be 
dealt with by the orthopaedic surgeon. 

It may be well to mention that I have adopted the name poliomyelitis 
anterior as best representing the disease as we now know it. It has been 
called with less reason by various names, such as infantile paralysis, essen- 
tial paralysis of Ghildren, acute atrophic spinal paralysis, myelitis of the 
anterior horns, myogenic paralysis, dental paralysis, and poliomyelitis anterior 
acuta. 

I have some cases here such as you will be likely to meet with in your 
practice, and I shall now examine them before you. 

This little girl (Case 311, page 683) is nine years old. 

She was perfectly well up to the time of an attack, which came on suddenly and with- 
out known cause. She is said to have fallen while she was playing, but no injury of the 
leg could be detected, though she was carefully examined under ether. The exact date of 
the attack is not known, but it was some time ago. Her general health is reported to have 
been very good, and she seems to be bright mentally. She is, as you see, well developed, 
and has a good color. Nothing abnormal has been detected on physical examination of the 
lungs, thorax, abdomen, or other organs. The pulse is regular and of good strength. The 
left leg shows considerable atrophy, being 4.37 cm. (If inches) smaller than the right in the 
calf and 2.5 cm. (1 inch) in the thigh. The leg is somewhat cyanotic, and is cold to the 
touch. There is marked weakness of the muscles below the knee, especially the exten- 
sors of the foot and toes. When she is lying in bed the movements of the thigh are 
performed with some strength. On walking she rotates the leg outward, so that the 
foot is at right angles with the line of motion, and she drags the toes. The joints are 
freely movable. Nothing abnormal has been detected in connection with the spine, which 
presents the condition of a movable lateral curvature, due to the shortening of the affected 
leg. 

She is being treated by massage, electricity, applications of hot cloths twice daily for 
half an hour, and by apparatus. 

She represents the condition of poliomyelitis anterior of the left leg, and, although she 
may receive some slight benefit from treatment, the probability is that she will always be 
lame. 



ORGANIC NERVOUS DISEASES. 



683 



This boy (Case 312) is twelve years old. 

He is said to have had rheumatic fever when he was thirteen months old. It was 
noticed that he dragged his right leg when creeping, and this leg has evidently been affected 
ever since he began to walk. The leg is atrophied, and there is a condition of valgus in 
the foot. There is slight permanent flexion in the knee, and the hip is also slightly flexed. 

Case 311. 




Poliomyelitis anterior. Left leg. Female, 9 years old. 



The movements of the limb are otherwise good. The adductors are in good condition. 
The abduction is chiefly accomplished by means of the tensor vaginas femoris. 

This case is evidently one of poliomyelitis anterior^, with valgus of the right foot. 

This infant (Case 313, page 684), twenty months old, is an unusual and interesting 
case of infantile paralysis of the abdominal muscles. 

He is stated to have always been healthy until five weeks ago, when on coming into the 
house he vomited and two days later limped a little. "When the infant cries you see that 
the abdominal walls bulge, especially on the left side. The motion of the left leg is very 
free, but slightly flaccid. The patellar reflex is absent, and he sits up very feebly. 

This little girl (Case 314, page 684) is two and one-half years old, and presents the 
same condition as the previous case. 

She has a sister who is said to have had an attack of poliomyelitis anterior when she 
was ten months old. No other history has been obtained about this case, except that she 
was well and strong until this attack, which occurred six weeks ago. The onset of the dis- 



684 



PEDIATRICS. 



ease was sudden, and was accompanied by high fever, followed in three days by complete 
paralysis of the muscles of the upper and lower extremities of the body and of the head. The 
arms and head soon recovered. She is unable to sit up alone, and the abdominal muscles 
are paralyzed to such an extent on the left side that, as you see, they are flaccid, bulge out, 



Case 313. 



Case 314. 





Poliomyelitis anterior. Abdominal muscles, 
left side. Male, 20 months old. 



Poliomyelitis anterior. Abdominal muscles, 
left side. Female, 2)^ years old. 



and do not react normally. The left leg is perfectly flaccid. The knee-jerks are absent. 
The surface temperature is diminished, and there is atrophy of the legs. 

(Subsequent history.) Under treatment with electricity and massage, complete recovery 
took place. 

The next case (Case 315, page 685) is that of a boy (I.), six and one-half years old, 
who was apparently healthy at birth, and who has never had any illness. 

When he was one year old he was noticed to have some motor disturbance of the left 
leg. On examination of the leg the surface temperature is found to be diminished, the 
knee-jerk is absent, and there is an atrophy of 5 cm. (2 inches) of the thigh and 6.5 cm. 
(2 J inches) of the calf. There is also 3.7 cm. (1^ inches) shortening in the leg. The child 
walks, as you see (II.), with a marked limp of the left leg, and there is the condition of 
flail-joint in his left knee and ankle. 

These symptoms, without any further history of the case, justify us in making a diag- 
nosis of disease of the spinal cord rather than of the brain. This is a typical case of the 
appearances presented in the advanced stages of a severe case of poliomyelitis anterior. 



ORGANIC NERVOUS DISEASES. 



685 



This girl (Case 316, page 686), sixteen years old, represents very well the results which 
may occur from an attack of poliomyelitis anterior. 

She is said to have had some disturbance in her left leg following a fall from a high 
chair when she was seven months old. She did not walk until she was eight years old, and 
has been lame ever since. She came under my observation at the hospital when she was 
thirteen years old, and at that time presented the evidences of a long-standing paralysis of 
spinal origin. The knee-jerk was absent. The left leg was cold and atrophied, and the 



Case 315. 





Poliomyelitis anterior. Flail leg, left side. Male, 63^ years old. 



foot was in the valgus position. She has, you see, a lateral curvature, due to paralysis of 
the muscles of one side of the back. She has shown only slight improvement under treat- 
ment for the last three years. 

Here is a little girl (Case 317, page 686), five years old, who, as you see, has paralysis 
of both legs. 

She was well and strong until about her third year, when she had an attack of whoop- 
ing-cough. During this attack she also had some other illness, which was characterized by 
fever and pain in the back. The loss of power of her legs dates from this time, and is said 
to have been gradual. She is fairly well developed, and the paralysis has affected both 
legs and thighs as well as the psoas and iliac muscles. There is marked atrophy, and 
the reflexes are absent. 

You notice in this case that the limbs are held apart and are flaccid. If the case were 
one of cerebral paralysis there would be in place of this flaccid condition a contraction of 
the adductors of the thigh, which would have been apt to hold the limbs closely together. 



686 



PEDIATRICS. 



At times this contraction would perhaps be so strong as to prevent the limbs from being 
drawn apart. 

The prognosis for complete recovery in this case is unfavorable. 

The treatment will be of a general nature, such as I have already explained to you 
should be adopted in cases of this class. 



Case 316. 



Case 317. 





Poliomyelitis anterior. Talipes varus . 
Lateral curvature. Female, 16 years 
old. 



Poliomyelitis anterior. Paralysis of both legs. 
Female, 5 years old. 



This little girl (Case 318, page 687), five years old, is a case of poliomyelitis anterior 
which has affected the right leg. 

"When she was three years old she fell from a step, and was seized with a sudden 
attack of paralysis of the right leg. A month later she walked with toe-drop of the right 
foot and slightly of the left. The skin of the limb is not especially cold or blue. The 
right thigh measures 24.1 cm. (about 9|- inches), the left thigh 24.3 cm. (9| inches). The 
right calf measures 16.2 cm. (6J inches), the left 17.5 cm. (7 inches). The patellar reflex 
is absent on the right side and very slight on the left. The right leg is 1.2 cm. (j- inch) 
shorter than the left. 

Under the application of massage and the use of various mechanical apparatus there 
has been slight improvement. 

This boy (Case 319, page 687), eleven and one-half years old, has a good family history. 



ORGANIC NERVOUS DISEASES. 



687 



and is said to have been swung about by his feet when he was seven months old, to which 
the family attribute the present condition of his right foot. 

The anterior portion of the foot is flexed, as you see, at a sharp angle at the medio- 
tarsal joint. The foot can be easily bent to a right angle, but not beyond. Tense bands 
of plantar fascia can be felt when the foot is straightened out, but it can be brought into 
position by the use of considerable force. The length of the legs is equal. There is 1 cm. 
(about I inch) atrophy in the right calf and 0.6 cm. (i inch) of the right thigh. 



Case 318. 



Case 319. 





Poliomyelitis anterior. Paralysis of right 
leg. Female, 5 years old. 



Poliomyelitis anterior. Talipes equinus on 
right side. Male, 11>< years old. 



He represents the condition of talipes equinus, the result of a contraction of the flexor 
muscles following an attack of infantile paralysis. 

I have also here a boy (Case 320), twelve years old, who illustrates a case of polio- 
myelitis anterior secondary to erysipelas. 

He had an attack of erysipelas when he was fourteen months old. The erysipelas 
lasted for about one month, and was followed by an attack of diarrhoea which lasted for six 
weeks. It was noticed that the infant was weak and had little power in the left leg about 
one week after the beginning of the erysipelas. After recovering from the diarrhoea he 
began to walk a little, but with a limp, which he has had ever since. The leg has since 
been growing smaller, and he has lately shown no improvement whatever. There has 
never been any pain in the leg. He walks with a decided limp, and the foot is brought to 
the floor with a slap. The knee bends backward beyond its proper position. The leg is 



688 PEDIATRICS. 

much atrophied, the right thigh being 11.2 cm. (4 J inches) less than the left, and the leg 
7.5 cm. (3 inches) less than the left leg. The leg and foot of the affected limb are slightly- 
colder to the touch than those of the other. On raising the foot of the affected limb it is 
seen that hyperextension can be produced to an angle of 140°. 

In this case I shall advise apparatus to prevent the further formation of flail-joint at 
the knee, which is evidently now present. 

PARALYSIS CAUSED BY CARIES OP THE SPINE.— In cases 
of paralysis caused by caries of the spine the lesion is essentially a com- 
pression of the cord : this is usually slow in its progress, and it is doubtful 
whether in it a true inflammation occurs even in the beginning. The con- 
dition resulting from compression occurring in the course of caries of the 
spine may be found in any part of the cord. It is most frequently met 
with in disease of the dorsal region, though it may occur in the cervical and 
lumbar regions. In caries of the spine the compression of the cord is not 
often the result of pressure from the vertebrae, but usually is caused either 
by an abscess in the vicinity of the diseased vertebrae, or more commonly 
by a thickening of the meninges. 

When the lesions of the cord are of any considerable extent, ascending 
and descending secondary degenerations follow after a time. If the process 
ceases, it leaves a certain amount of sclerosis of the cord at the seat of the 
disease. This may be very slight, or the cord may be considerably reduced 
in size and yet may transmit normal nervous influences. 

Symptoms. — The onset of the disease is sometimes quite sudden, but 
more frequently it is rather gradual. The symptoms vary according to the 
part of the cord which is affected. 

When the lesion is in the dorsal or the lumbar region the onset is 
represented by numbness and weakness in the legs. This is quickly fol- 
lowed by a paralysis which may become complete in a short time. 

If the lesion is below the level of the sixth dorsal vertebra, the legs 
alone are affected ; if on a level with this point, the abdominal muscles are 
involved. Sensation up to nearly the level of the lesion may be diminished, 
or even lost entirely. In regions above the lumbar enlargement the reflex 
reactions are exaggerated and ankle-clonus soon appears. 

When the disease affects the cervical enlargement, or any portion of the 
cord above, all the extremities are apt to be paralyzed. In severe cases 
there will be retention of urine, with subsequent incontinence. The bowels 
are usually constipated, but incontinence of faeces is sometimes present. 

In lesions of the lumbar enlargement the knee-jerks will be lost. 
Trophic changes in the limbs are not marked, but the muscles are somewhat 
wasted, and rigidity may develop. Bed-sores are apt to form. The reaction 
of degeneration is not present. 

The characteristic picture of lesions in the dorsal region caused by caries 
of the spine is paraplegia. 

Diagnosis. — The disease is to be differentiated from poliomyelitis ante- 
rior, in which disease monoplegia is more common than paraplegia, and in 



ORGANIC NERVOUS DISEASES. 689 

which the reflexes are lost and the action of degeneration is present. In 
addition to this means of making a differential diagnosis, the absence of 
initial fever and prodromata, of disturbances of sensibility, of paralysis 
of the sphincters, and of a tendency to bed-sores in poliomyelitis anterior 
is of great aid in differentiating it from the results of caries of the spine, 
where rigidity of the limbs, increased reflexes, and contractures are promi- 
nent symptoms. 

The differential diagnosis from cerebral paralysis is more difficult, as 
the condition of the limbs is similar in both. The diagnosis is made by 
the absence of all cerebral symptoms, and by the presence of such special 
symptoms as rigidity and prominence of the vertebrae in caries of the spine. 

Prognosis. — The prognosis in these cases is in general favorable. A 
certain number of cases remain uncured, but nearly all recover under treat- 
ment, although the condition may persist for months. 

Treatment. — The treatment of these cases is, as a rule, to be directed 
to the caries, and consists essentially in perfect rest on a rectangular bed- 
frame. Massage and electricity are sometimes of assistance when applied 
to the paralyzed limbs. Where no improvement occurs after several months, 
laminectomy must be considered; and there has been a case (Case 321) at 
the Children's Hospital where improvement followed this operation. In 
this instance an abscess was pressing upon the cord, and on its being dis- 
covered and emptied recovery took place. The operation was performed by 
Dr. H. L. Burrell. 

HEREDITARY ATAXIA (Friedreich's Disease).— Hereditary ataxia 
is a very rare disease. It is an organic affection of the spinal cord, usually 
occurring in several members of a family and developing in later childhood. 
The names family ataxia and generic ataxia have also been used. 

Pathology. — The pathology of the affection is a slow, progressive 
degeneration of the posterior and lateral columns of the cord. 

Symptoms. — The characteristics of this disease are its slow develop- 
ment, staggering gait, loss of muscular power, nystagmus, sometimes loss 
of knee-jerk, frequent disturbance of speech, and finally complete helpless- 
ness with mental impairment. 

Prognosis and Treatment. — The prognosis of hereditary ataxia is 
always unfavorable, and there is no known remedy which is of benefit. 

LOCOMOTOR ATAXIA. — In connection with this degeneration of 
the posterior and lateral columns of the cord which occurs in hereditary 
ataxia, I shall merely mention the degeneration of the posterior columns of 
the cord (locomotor ataxia), as this disease is almost unknown in childhood. 
The disease as it occurs in children usually involves the lateral as well as 
the posterior columns of the cord, and is thus closely related to Friedreich's 
disease. 

Locomotor ataxia is to be distinguished from multiple neuritis, which 
it sometimes closely resembles, the pain, ataxia, and loss of knee-jerk often 
occurring in both. The diagnosis from multiple neuritis is to be made 

44 



690 PEDIATRICS. 

chiefly by the presence of ocular symptoms in locomotor ataxia, such as the 
Argyll-Eobertson pupil. (In this condition the pupil does not react to 
light, but does react to accommodation.) In addition to this means of dif- 
ferential diagnosis, the tenderness of the nerve-trunks in multiple neuritis 
does not occur in locomotor ataxia. You must also remember that locomotor 
ataxia is incurable, while multiple neuritis always recovers. 

Locomotor ataxia may be differentiated from Friedreich's ataxia by 
(1) the fact that it is not of hereditary origin, (2) the absence of nystagmus 
and of mental symptoms, and (3) the ataxic and shuffling gait. 

SYRINGOMYELIA. — As defined by Osier, syringomyelia is a glio- 
matous new formation about the central canal of the spinal cord, with 
cavity formation. This disease is so rare in children that I shall merely 
state that it is now regarded as a gliosis, a development of embryonal 
neurogliar tissue in which hemorrhage or degeneration takes place with 
the formation of cavities. 

In this disease we usually find a diminution of sensation to heat and 
cold, according to the site of the lesion, which is commonly a point in the 
upper dorsal or the lower cervical region. There is apt to be a weakness of 
one or both arms, accompanied by marked wasting. There is also usually 
some weakness in the legs. The reflexes are increased, and a spastic con- 
dition is likely to result. These symptoms are usually accompanied by 
marked lateral scoliosis. 

In typical cases the diagnosis is easily made where there is an amyo- 
trophic paralysis of one or both of the upper extremities, with retention of 
tactile sensation and loss of thermic and painfhl sensation beloAv the dorsal 
region, and a weakness of the lower extremities, with a tendency to spastic 
rigidity. 

Syringomyelia is an incurable disease, and the treatment is therefore 
usually limited to correcting, if possible, the lateral curvature which fre- 
quently accompanies it. 



OEGANIC XERVOrS DISEASES. 691 

IvECTURE XXXIII. 

BRAIN AND CORD. 

MrLTiPLE Cerebro-Spixal Sclerosis. — Cerebro-Spixal Meningitis. 

MULTIPLE CEREBRO-SPINAL SCLEROSIS.— By multiple scle- 
rosis of the brain and cord we mean a disease in which the nerve-elements of 
certain areas in the brain and cord are more or less replaced by connective 
tissue. The sclerosis which occurs in these cases, however, is not a distinc- 
tive lesion of multiple cerebro-spinal sclerosis, as it is the same that occurs 
in other sclerotic conditions of the nervous system. It is simply the 
multiple distribution of these areas which is pathognomonic of the disease. 
The disease has also been described under the name of disseminated sclero- 
sis, insular sclerosis, focal sclerosis, herdsklerose, and sclerose en plaques. 

Etiology. — The etiology of the disease is obsciu-e ; but heredity appears 
to be one of the causes of multiple sclerosis, and traumatism, shock, and 
various acute diseases, especially those of an infectious character, have an 
etiological significance. 

Patholog-y. — Only a small number of autopsies of this disease have 
been made in children. 

The characteristic feature of the disease by which it is distinguished from 
other sclerotic diseases of the brain and cord is the erratic and multiple dis- 
tribution of the sclerosis. The sclerotic patches may occur in the bram or 
in the cord, or in both, and they are perfectly irregular as to the parts of 
the cerebro-spinal system which they involve. According to Osier, there is 
an increase in connective tissue of the sclerosed patches, and their fibres are 
denser and firmer than normal. The gradual growth destroys the medulla 
of the nerves, but the axis cylinders persist in a remarkable way. 

Symptoms. — The onset of the disease may be rapid or slow, but is 
more likely to be rapid. According to Pritchard, the child is noticed, after 
perhaps a blow on the head, or a shock or fright, or without any apparent 
cause, to tremble. In some cases the disease may be ushered in by a convul- 
sion. In connection with the tremor, nystagmus may appear as an early 
symptom, but, as a rule, it is a later one. The gait is usually affected early, 
the movements being clumsy or staggering. Among other early symptoms 
strabismus and diplopia may be mentioned. Headache and vertigo are 
probably not infrequent, although in young children it is somewhat difiicult 
to determine the presence of these symptoms. Exaggeration of the reflexes 
which depend upon the location of the lesion is an early symptom in some 
cases, and may be associated with ankle-clonus. The later symptoms are 
disturbance of speech, mental weakness, slow muscular wasting, and paralysis 
of the extremities. 



692 PEDIATRICS. 

Diagnosis. — The differential diagnosis of multiple cerebro-spinal sclero- 
sis is to be made chiefly from hereditary ataxia, as there is no other disease 
of the nervous system occurring in children which especially simulates it. 
Although in both diseases ataxia, nystagmus, and defects of speech occur, 
and although tremor is a common symptom of both, yet these symptoms 
differ somewhat in their form. 

According to Pritchard, tremor is a common symptom in multiple 
cerebro-spinal sclerosis in children, while in hereditary ataxia it occurs in 
only a certain proportion of cases ; in the former disease it is of the volun- 
tary type, in the latter it is of the choreiform variety. Again, in hereditary 
ataxia the affection of the speech occurs, as a rule, later than in sclerosis. 
On the other hand, ataxia of the extremities is less constant in sclerosis 
than in hereditary ataxia, and the inability to stand with the feet together 
and the eyes closed, while common in hereditary ataxia, is rarely observed 
in sclerosis. Various paraesthesise which not infrequently occur in hereditary 
ataxia, especially the girdle sensation^ are not common in children affected 
with sclerosis. 

In addition to these other clinical differences there are three symptoms 
which afford a marked contrast in the two diseases. These are (1) the con- 
dition of the reflexes, especially that of the patellar tendon ; (2) the mental 
state ; and (3) the tendency to convulsive seizures. In multiple sclerosis 
the knee-jerk is commonly exaggerated and rarely abolished, while in 
hereditary ataxia it is often abolished. The mental condition is commonly 
dulled at some stage of the disease in multiple sclerosis, and is usually in 
the form of a simple dementia. In hereditary ataxia, on the contrary, the 
intellect is unimpaired, mental weakness being exceptional. Convulsions 
are quite common in sclerosis and are rare in hereditary ataxia. 

A differential diagnosis should also be made from chorea, which can be 
eliminated readily by the absence of tremor, by the presence of incoordinate 
movements, and by the absence of nystagmus and of true ataxia. 

Prognosis. — The prognosis in multiple cerebro-spinal sclerosis for per- 
manent recovery is very unfavorable. The disease may be arrested tempo- 
rarily, but improvement in the general condition of the child, as a rule, 
merely marks a remission. The child rapidly becomes so helpless that there 
is a corresponding liability to complications and to death. 

Treatment. — There is no drug which appears to have any effect upon 
the disease, the treatment being wholly symptomatic. The general health 
of the child should be carefully attended to, and in this way the inroads 
of the disease on the nervous system can be combated. 

CEREBRO-SPINAL MENINGITIS.— By cerebro-spinal meningitis 
we mean an acute infectious disease characterized by a leptomeningitis of 
the brain and spinal cord. 

Although this disease is usually classed under the infectious fevers, it 
seems to me to be associated more naturally with diseases of the nervous 
system, because the main pathological lesions are found in the brain and in 



ORGANIC NERVOUS DISEASES. 693 

the spinal cord. However closely it may in the future be proved to be 
associated Avith other diseases, such as pneumonia, and however firmly we 
may believe that its cause is a microbe as in the other diseases of the infec- 
tious class, still the salient symptoms by which we can make our diagnosis 
are those produced by central organic nervous lesions. The disease does not 
appear to be contagious. It may be acute or chronic. It may occur as a 
primary disease or in connection with some other infectious disease, such as 
acute lobar pneumonia. 

Etiology. — Cerebro-spinal meningitis at times occurs in wide-spread 
epidemics. It is also met with in a sporadic form. Although there has not 
yet been made a sufficient study of the epidemic form of the disease to allow 
me to state much that is definite about its causation, it is probable that it is 
the same as in the sporadic form. From the sporadic cases which have 
been carefully studied it is evident that certain bacteria are the cause of the 
disease. The most common organism which has been found is the pneu- 
mococcus of Fraenkel, but the streptococcus and staphylococcus pyogenes 
aureus have also been found in a few cases. No distinction except a bac- 
teriological one can be made between the cases in which these bacteria are 
found ; nor can any be made between the epidemic and the sporadic cases, 
as they have the same symptoms. Although there is supposed to be a 
close connection betrv^een cerebro-spinal meningitis and pneumonia, yet the 
former disease is frequently found without the lesions of pneumonia being 
present. 

Pathology. — The pathological lesions which represent this microbic 
form of cerebro-spinal disease are chiefly an inflammation of the pia mater, 
with its accompanying serous, fibrinous, or purulent exudation. The brain 
and cord may be involved. Foci of hemorrhage and of encephalitis are 
sometimes foimd. The prominent primary lesion which produces the 
typical, uncomplicated picture of the acute variety of cerebro-spinal menin- 
gitis in its early stage is a leptomeningitis, and the disease can well be 
looked upon as a microbic leptomeningitis. 

As has been well stated by Delafield and Prudden, the degree of the 
lesion in the brain varies greatly, depending upon the period at which death 
occurs. At times, when death occurs early in the disease, no macroscopic 
change will be evident. Microscopic examination in these cases, however, 
shows a moderate degree of extravasation of leucocytes in the vicinity of 
the vessels. In well-marked cases the pia mater and the cord are more or 
less densely infiltrated with serum, fibrin, and pus. This pathological con- 
dition may be found over the convexity and base of the brain, and is fre- 
quently most marked in the latter situation. In the cord the infiltration 
may occur over the anterior and posterior surface, and in some cases, prob- 
ably owing to the recumbent position of the patient, it is most marked on 
the posterior surface. The ventricles of the brain and the central canal of 
the cord may contain turbid serum mingled with pus-cells and sometimes 
blood-cells. The membranes and underlying nervous tissue may be hyper- 



694 PEDIATEICS. 

semic and the seat of capillary hemorrhages. In protracted cases the ven- 
tricles may be dilated with serum. 

In addition to these characteristic lesions of the disease^ there are a number 
of secondary changes in different parts of the body, which are not constant, 
but which occur with sufficient frequency to warrant their mention. Thus, 
there may be subserous punctate hemorrhage in the endocardium ; petechise 
in the skin; hyaline and granular degeneration in the voluntary striated 
muscle ; occasional multiple abscesses in various parts of the body ; suppu- 
rative inflammation of the joints ; parenchymatous degeneration of the 
heart, liver, and kidneys ; swelling of the gastro-enteric lymphatic system, 
and metastatic choroiditis. 

The lesions are essentially the same in the epidemic and sporadic cases 
of acute cerebro-spinal meningitis. 

In the form which from its length may be called chronic the pathology 
has not been determined, as a sufficient number of autopsies of this variety 
has not yet been obtained. It is, however, possible that the various later 
symptoms of organic central disease which occur in some of these cases, 
and especially in those which do not recover, may be produced by the lesions 
of hydrocephalus and cerebral abscess. 

Symptoms. — The disease is usually sudden in its onset, attacking at 
times perfectly healthy children. The prominent symptoms are intense 
headache, photophobia, and at times convulsions, pain, hypersesthesia, vom- 
iting, delirium, and, later, coma ; also sensitiveness to sound and to touch. 
Tenderness on pressure over some portion of the vertebral column is found 
not uncommonly. The temperature in the more severe cases is high, 40.6° 
to 41.1° C. (105° to 106° F.); usually, however, it is 38.3° to 38.9° C. 
(101° to 102° F.). There is no regular temperature curve; in fact, the 
symptoms, temperature, pulse, and respiration vary in different cases. The 
pulse is usually quick ; the respirations are rhythmical, but somewhat quick- 
ened. The bowels are usually constipated. 

Strabismus is a common symptom, and rigidity and retraction of the 
neck and back (opisthotonos) are soon noticed. The knees are usually 
drawn up. The child emaciates rapidly. The pupils are altered. It is 
not uncommon to find metastatic choroiditis with exudation of pus into the 
vitreous (Wads worth). There is often bilateral loss of hearing. Remis- 
sions in the symptoms are frequent. A tache c^rehrale can at times be 
found. The spleen, especially in acute cases, is enlarged. If the brain and 
cord are also decidedly involved, symptoms corresponding to the locality 
and degree of the lesion appear. This is especially noticeable in the chronic 
form, where the disease has lasted for some months. Pneumonia, arthritis, 
pleuritis, and pericarditis may arise as complications. 

Diagnosis. — The prominent symptoms on which you must rely in dif- 
ferentiating cerebro-spinal meningitis from tubercular meningitis, for which 
it would be most likely to be mistaken, are the sudden onset, extreme head- 
ache and hyperaesthesia, opisthotonos, herpes, and regular pulse in the 



OEGANIC NERVOUS DISEASES. 695 

cerebro-spinal disease as compared with the usually slower progress and 
milder symptoms of the tubercular. In some cases the onset is not so 
sudden, and difficulties have arisen in the differentiation from typhoid fever 
and pneumonia ; but, except in the rather rare meningeal types of these latter 
diseases, the diagnosis will in a few days become clear. 

In young infants the symptoms of cerebro-spinal meningitis may be 
merely a heightened temperature with clonic convulsions, so that the diag- 
nosis cannot be made during life from the various forms of reflex convul- 
sions which may occur at this age, and cerebro-spinal meningitis can only 
be suspected. A case illustrating this fact was seen by me in consultation 
with Dr. W. L. Eichardson. 

A male infant (Case 322), healthy at birth, was suddenly attacked when it was six 
days old with general clonic convulsions, accompanied by a temperature of 40° C. (104° F.) 
in the first twelve hours, and afterwards to the time of its death by a temperature of 
38.8° C. (102° ¥.). The attack followed a period of nervous excitement in the mother, 
who was nursing it, and who in other respects showed no abnormal symptoms. There were 
no symptoms of cerebro-spinal meningitis, such as retraction of the head or opisthotonos, 
and in the intervals between the convulsions, which occurred about every hour, the infant 
seemed perfectly well. It did not vomit, and did not have any abnormal symptoms con- 
nected with the eyes. The convulsions, which constituted the only symptom, continued, 
and on the second day of the attack the infant died suddenly. 

The report of the autopsy, made by Dr. Whitney eighteen hours after death, was as 
follows : 

Eigor mortis well marked. Lividity of the dependent parts of the body, and in small 
separated patches over the arms, legs, and chest. 

The calvaria presented nothing abnormal. The inner surface of the dura was covered 
with opaque yellowish patches of lymph, especially marked over the base of the skull. The 
vessels of the pia mater were markedly injected, and its meshes were filled with an opaque 
greenish-yellow exudation. This exudation extended over the entire brain and into the 
spinal canal. Microscopic examination showed the presence of large micrococci, usually 
associated in pairs, two of which were sometimes united with a chain of four (pneumococcus). 

The heart was normal, and its cavities were filled with dark fluid blood. 

The lungs were not fully retracted, and were engorged with dark blood, which was so 
abundant as to suggest extravasation into the alveoli. The pleural surfaces were perfectly 
smooth. 

The abdominal organs — spleen, liver, and kidneys — were markedly injected with blood, 
but were otherwise normal. 

The stomach and intestines presented nothing abnormal. 

The pathological diagnosis was, acute purulent cerebro-spinal meningitis, and general 
venous congestion. 

Prognosis. — The prognosis, where the child is young and the onset is 
violent, with high temperature and continuous convulsions, is very serious ; 
but, even in the apparently fatal cases where coma has intervened, a change 
may take place and the child recover. The first two weeks are usually the 
critical periods, so far as the acute form of the disease is concerned. The 
disease varies in duration, sometimes lasting for only a few days, in other 
cases for a number of weeks ; but in some cases it lasts for months, wlien it 
constitutes the chronic form, which is apt to prove fatal, both from exhaus- 
tion and from the development of more serious central nervous lesions. 



696 PEDIATRICS. 

Treatment. — The treatment of cerebro-spinal meningitis varies ac- 
cording to the severity of the symptoms. In most cases sedatives, such as 
the bromides, are indicated, and where the pain is severe opium in consider- 
able doses is often needed. The ice-bag or Leiter's coil applied to the head, 
and absolute quiet in a darkened room, are important adjuvants to the treat- 
ment. In many cases the pulse becomes so weak and the prostration so 
marked that stimulants are needed until convalescence is established, when 
they can usually be replaced by tonics. In some cases the hypersesthesia 
and general sensitiveness to noise, light, and motion in the room are so 
extreme and so characteristic that the attendants should be cautioned not 
to touch the child or the bed unnecessarily, and absolute quiet should be 
enforced in the room and throughout the house. 

I have already told you that, as a rule, cerebro-spinal meningitis in 
children is a disease which is characterized by acute onset. This case, which 
I take from my notes, is illustrative of this fact : 

A boy (Case 323), thirteen years old, had never had any especial diseases, but had been 
rather delicate for a number of months. He went to a Christmas party on December 25, 
and on returning from the party complained of the motion of the sleigh in which he rode 
home. On the following day, in the afternoon, he was found to be listless, to have his 
tongue coated but not dry, and to have a temperature of 40.5° C. (105° F.) and a pulse of 
140. He complained of tenderness and pain in the back of his neck ; there was also tender- 
ness in the abdomen. He appeared to be somewhat dull. 

On the following day the temperature in the morning was 39.4° C. (103° F.), and the 
pulse was 120. He was much more dull and apathetic than on the previous day, and in 
the afternoon became delirious. In the evening he had involuntary passages of urine and 
loose discharges from the bowels. His temperature was 40° C. (104° F,). 

On the following day his temperature was 39.4° C. (103° F.), and the respirations 
varied from 40 to 80 and were regular. He was unconscious. Subsultus tendinum was 
present. There was retraction of the head. The pupils did not respond to light, but were 
equal in size. A tache cerebrate was present. 

On the evening of the following day, four days from the onset of the disease, he died. 

The autopsy made by Dr. Gannett showed the convex surface of the entire brain and 
cord to be covered with a thick exudation of pus, the spleen to be enlarged, and the case to 
be one of acute cerebro-spinal meningitis. 

I have here in the wards a child (Case 324, page 697), two years old, who was brought 
to the hospital on the 21st of the month with the history that it had been showing symptoms 
of malaise for six weeks. Two weeks previous to entering the hospital it had a convulsion, 
and the indefinite and general symptoms had become more pronounced. There had been 
loss of appetite, with constipation ; at times vomiting, slight cough, and a heightened tem- 
perature. 

You see on examining the child the position which it assumes in bed. The head is re- 
tracted, and the muscles of the neck are rigid. The eyes are staring, but the pupils react to 
light. There is at times, though not now present, slight opisthotonos. On examining the 
child in front (I.), you see that the abdomen is retracted. Looking at it from behind (II.), 
you see that the occiput touches the back of the neck, and that the emaciation is extreme, 
so that the vertebrae and ribs have become quite prominent. The child is apparently un- 
conscious, and does not notice objects which are brought before its eyes, although the ej^es 
are open. It moans at times, and sometimes the legs are drawn up. No efflorescence has 
been detected anywhere on the skin. Although, as I have already told you, the onset of 
cerebro-spinal meningitis may be acute, yet in certain cases the prodromal symptoms are 
of a subacute character and somewhat prolonged, as has occurred in this case, which seems 



OEGANIC NERVOUS DISEASES. 



697 



to be one of this disease. It has been in the hospital for seven days, which would make 
the time since it was first noticed to be sick seven weeks. Since entering the hospital 
the temperature has varied from 36.6° to 38° C. (98° to 100.5° F.). At intervals it has 
vomited and has apparently been unconscious. Sometimes it has cried out sharply, as 
though in pain. A tache cerebrate has been found at times, and the retraction of the head 
has been almost continuous. 

The continuous retraction of the head, with at times opisthotonos and unconsciousness 
without the serious cerebral symptoms which after the fourth or fifth week would accom- 
pany an attack of tubercular meningitis, and the absence of any symptoms which point 




Cerebro-spinal meningitis. Male, 2 years old. 



towards disease of the thoracic or abdominal organs, lead me to make the provisional diag- 
nosis in this case of cerebro-spinal meningitis. From what I have told you in a previous 
lecture in speaking of tubercular meningitis, especially of the recurrent form, an instance 
(Case 272) of which I showed to you at that time, you will understand that the diagnosis 
must be somewhat uncertain in a sporadic case of this kind until the disease has been under 
observation a still longer time. 

The treatment of this case is simply the frequent administration of milk, with the addi- 
tion of stimulants when indicated by the weakness of the pulse. The child has been in 
so apathetic a condition that the use of any drug has been unnecessary. Although at 
times it has cried out as if in severe pain, yet these attacks have not been sufficiently long 
to indicate their control by an opiate. 

(Subsequent history.) During the following month the child remained very much the 
same as described above. The head was retracted at times, and the emaciation became 
extreme, the abdomen being very much sunken (boat-shaped). In the next two weeks the 
nourishment was taken more readily, the head was less retracted, and he began to notice 
objects around him, but he vomited once or twice nearly every day. The temperature at 
this time became normal. 

This chart (Chart 26, page 698) marks the temperature from the day when the child 
entered the hospital, in the sixth week of his illness, until the temperature became normal, 
nine days afterwards. 

One month later, which was two months from the time when the child entered the 



698 



PEDIATRICS. 



hospital, he was able to sit up without help. There was no retraction of the head, but the 
muscles of the neck were very rigid, and the head showed a tendency to fall back. 

During the following month the child continued to improve slowly, increased in weight. 











CHART 26. 










Days of Disease. 






42 43 44 45 46 47 48 49 50 




F. 

1C7° 

106° 
105° 
104^ 
103° 
102° 
101° 
100° 
99° 

NORM'L 

TEMP. 

98° 
97° 
96° 
95° 


ME 


ME 


ME 


so: 


mj: 


MIE 


so: 


ME 


M_E 


c. 

41.6° 

41.1° 

40.5° 

40.0° 

39.4° 

38.8° 

33.3° 

37.7° 

37.2° 
37.0° 

36.6° 

36.1° 
35.5° 
35,0° 










































































i 




































.1 


y 


\ i 






J 




Ji 




¥ 


1/ 


v 






/ 




/ 




/... 




-V- 


^ 


^ 


/- 


^ 


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..... 























































recovered his appetite, and when seen one month later was found on physical examination 
to be in a normal condition. Here is a picture (III.) of the child, which was taken after an 
examination made by me which showed him to be in a normal condition in every respect. 




Cerebro-spinal meningitis. Recovery after 4^% months. 

This next child whom I have to show you is a girl (Case 325), eight years old, who 
apparently represents that form of cerebro-spinal meningitis which is designated chronic, 
and only a few cases of which have been reported. 

The child entered the hospital two days ago. Her parents are said to have been 
healthy, and there is no evidence of tuberculosis or syphilis in the family. A brother 
whom I saw in consultation died of cerebro-spinal meningitis. With the exception of an 
attack of measles and of whooping-cough, the child has not had any other diseases. The 
present illness began four and a half months ago. The child had not been entirely well 
since the attack of pertussis which occurred one year ago. 

The onset of this attack was sudden. She went to bed in fairly good condition, but 
woke up in the night delirious, screaming, and apparently not recognizing her parents. 
These symptoms continued until the following week. There were no convulsions. A week 
later vomiting occurred every two or three days. This was not dependent upon food, and it 
has occurred at intervals up to the present time. The bowels were constipated. There 
has been more or less opisthotonos from the beginning of the illness, and also in the begin- 
ning there was decided retraction of the head. The stiffness of the neck has gradually 



ORGANIC XEEYOUS DISEASES. 



699 



diminished, but at times has been present since entering the hospital two days ago. Up to 
the present time the child is said to have had constantly a heightened temperature, varying 
from 37.7° to 39.4° C. (100° to 103° F.), with a rapid pulse and quick respirations. ^SToth- 
ing abnormal has been found in the urine. There has been no efflorescence on the skin. 

About four weeks ago the child was noticed to be blind. This has occurred suddenly. 
The child has had constant headache, and shortly after the beginning of tlie attack showed 
a loss of power of motion in both legs. At times there has been incontinence of faeces and 
of urine. An examination of the urine showed it to have a specific gravity of 1015. to be 
normal in color, to have an acid reaction, and not to contain albumin or sugar. No evi- 
defice of syphilis was detected. She sometimes showed improvement in her general symp- 
toms and became conscious, but she has not been able to sit up or to walk. 

On physical examination you see (I.) that she is somewhat emaciated. 




Chronic intermittent cerebro-spinal meningitis. Tache cerebrale sho-wing on right thigh. 

S vears old. 



Female. 



There is extreme hypeniesthesia of the body and extremities. The slightest motion of 
the bed seems to cause discomfort and pain. An examination of the thoracic and abdominal 
organs shows that they are normal. The pulse is 80 and regular, the respirations are natural, 
the temperature is 37.7° C. (100° P.). This morning she had an attack which was charac- 
terized by spasmodic contractions of all the muscles 
of the body, lasting for about thirty seconds. At 
this time there was no loss of consciousness, and the 
child screamed for some time afterwards as though 
in pain. During the attack the pulse grew feeble 
and intermittent, the respirations slow and super- 
ficial, and the extremities cold. Brandy was given 
subcutaneously, and reaction took place, so that she 
is now comparatively comfortable. 

On examining the eyes (ll.) you will see that 
although the pupils react and the retina is evidently 
sensitive to light, yet apparently she is blind. 

You will notice in the middle of the eye a 
yellowish mass with an irregular border. Dr. Jack's 
report of the examination of the eyes is as follows : 

'• There is a very slight hypenemia in the ciliary region 
forward, and its pupillary edge is a little uneven 




Metastatic choroiditis occurring iu cerebro- 
spinal meningitis. 

The iris seems slightly pushed 
A vellowish or 5'ellowish-white reflex 



700 



PEDIATRICS. 



appears from the fundus of the eye even without the use of the ophthalmoscopic mirror, and 
it is easy to distinguish that this reflex does not come from the level of the lens, but that it 
is situated deeper. The tension of the eyeball is very much reduced, and there is very little 
tenderness on pressure." 

These yellowish appearances in the pupils are sometimes called pus emboli. The disease 
is due to embolism, and is called metastatic choroiditis with an exudation of pus in the 
vitreous. It occurs quite frequently in cerebro-spinal meningitis. It is to be difterentiated 
from glioma. Sometimes this yellowish mass fills the vitreous entirely, sometimes only in 
part. It may have blood-vessels on its surface. 

You see on drawing the finger over the right thigh that a decided tache cerehrale is 
produced, which lasts from ten to fifteen minutes. 

This is only the third case of this form of cerebro-spinal meningitis which has come 
under my observation. In both the other cases the children eventually died from a pro- 
longed sickness of many months, during which they at times seemed to be recovering. 
Cases have been reported by others, as by Henoch of Berlin, to have recovered, so that in 
this especial case we are not able to give a more definite prognosis. At present there is 
no lesion which I have detected that would prevent the child from recovering, although 
she will always be blind. On the other hand, she may eventually die from exhaustion. 



















CHAET 


27 




















Days in Hospital. 






1 


2 


3 


4 


5 


6 


7 


8 


9 


10 


11 


12 


13 


14 


15 


16 


1 7 


18 




F. 

107° 

106° 
105° 
104° 
103° 
102° 
101° 
100° 
99° 

^ORM'l 

TEMP. 

98^ 

970 

96° 
95° 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


Mi: 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


0. 

41.6° 
41.1° 
40.5'' 

40.0'^ 

39.4° 

38.8° 

38.3° 

37.7° 

372° 
37.0° 
36,6° 

36.1° 

35.5° 

35 0° 1 














































































































^ 




































•5 
































; 


I 


S5_ 
































/ 


I 


ts 

^ 






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,A 




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i 1 


s.^ 


h 


/ 




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— ^ 


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L. 






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y 
























































































. 



















Chronic cerebro-spinal meningitis. 



(Subsequent history.) After the above report the child remained in about the same con- 
dition. At times she screamed as though in pain, but she took her nourishment fairly well. 
She had one slight convulsive attack, which involved mainly the upper extremities, the lower 
extremities being only slightly contracted. During this attack her thumbs were turned in, 
her fingers clinched over them, and her arms, which were usually extended at her sides, were 
flexed at the elbows. Her face showed no sign of spasm, and during the attack the radial 
pulse was full, soft, and regular. After a few seconds the muscles again became relaxed, 
and there was no further tendency to contraction. The usual position in which she lay 
during the following weeks was with the thighs slightly flexed and abducted and the legs 
flexed at the knee, with the heels almost touching each other. About two weeks after 
entering the hospital the right leg became flexed on the thigh to such an extent that the 
knee almost touched the chin and the heel rested on the vulva. Any attempt to extend 
the leg made the child cry out as though in pain, the left leg being naturally extended 
in bed. This condition of the right leg continued for several days and then disappeared. 



ORGANIC NERVOUS DISEASES. 



701 



Some days later a slight convulsive attack took place, which seemed to affect the right side 
more than the left. 

This chart (Chart 27, page 700) shows the temperature during the eighteen days when 
the child was in the hospital. The pulse during this time varied from 68 to 100 ; the respi- 
rations sometimes varied from 34 to 52, but were usually about 28. 

The fingers were flexed most of the time, and there was so much rigidity of the limbs 
that the reflexes could not be satisfactorily determined. The pus embolus in the right eye 




lY. 




Chronic cerebro-spinal meningitis. Spastic condition of extremities 514 months after onset of the disease. 



seemed to be farther back from the plane of the iris than at the previous examination. The 
embolus of the left eye remained in about the same plane with the iris. The head was held 
rigid in any position in which it was placed, and she cried when it was moved. The pulse 
was 166, weak and compressible, the respirations were rapid, 42, the ala^ nasi moved some- 
what, and there was apparently a slight degree of dyspncea. The temperature in the axilla 
was 38.6° C. (101.5° F.). There was slight cyanosis of the cheeks and lips, and an eruption 



702 PEDIATRICS. 

of milia on tlie chest, apparently arising from her continually perspiring day and night. 
She lay in a stupor all the time, except when she was moved, when she would cry out. 
She showed no signs of understanding anything that was said to her. Sometimes she would 
be seized with an attack of rapid breathing lasting several hours. The bowels had been 
constipated up to within two days, when diarrhoea occurred. There was incontinence of 
fgeces and urine, but no vomiting. During the last few days previous to this examination 
the teeth were kept closed, and had to be forced apart when she was fed. She was reported 
to have had one week previous to this examination a convulsion, in which the head was 
drawn back, the body and extremities were rigid, and the eyes rolled up. The child cried out 
sharply just before the convulsion. A physical examination made at this time showed 
nothing abnormal in the chest or abdomen. 

Eighteen days after entering the hospital the child was 
taken to her home, so that the daily record could not be ob- 
tained. 

An examination made two weeks after she left the hospi- 
tal showed a spastic condition of the extremities and neck, as 
seen in these illustrations (Case 325, III. and lY., page 701). 
When seen by Dr. Bullard at this time the child took no 
notice of her surroundings, and her eyes when opened had 
a vacant expression, due largely to the mental condition, 
although at this time she was undoubtedly blind. The ex- 
tremities were much wasted, and were all in a condition of 
spastic rigidity. There was slight flexion of the thighs on the 
body and of the legs on the thighs, while the feet were ex- 
tended in nearly a straight line with the legs. 

The hand, as you see in this illustration (Y.), is flexed 

almost at right angles to the wrist. The proximal phalanges 

of the fingers are hyperextended, while the other phalanges 

Chronic cerebro-spinal men- ^^^ ^^^^^^ rj.^^ ^^^^^ -^ strongly adducted, and its distal 

mgitis. Spastic condition of . ^ ^ 

hand 5K months after onset of P^ialanx is flexed. 

the disease. This is a position of the hand frequently found in the 

later stages of spastic paralysis, and is due to the preponderant 
contraction of the flexors of the wrist and weakness of the interossei and lumbricales. 
(The child gradually grew weaker, and died of exhaustion a few weeks later.) 

I will also report to you another of these rare cases of chronic cerebro- 
spinal meningitis, which I saw in consultation with Dr. Townsend. 

The child (Case 326), a boy, four and a half years old, had been previously well, with 
the exception of an attack of measles when he was one year old. 

On May 9 he was suddenly attacked with vomiting, which continued at intervals 
for two days. From the beginning of the attack he complained of severe pain in the head 
and abdomen. On the second day of the attack there was much contraction of the head, 
and he was slightly delirious, although rational most of the time. The temperature was 
raised from the beginning of the attack. There were no convulsions. The bowels were 
not moved during the first week of the disease. When first seen by Dr. Townsend the 
pulse was 124 and regular, the temperature 38.8° C. (102° P.), and the respirations 20 and 
regular. There was slight opisthotonos. There were no contractions of the muscles of 
the limbs. The symptom of Kernig was present. There was no tenderness along the 
spine. The cutaneous sensibility was everywhere normal. There were no cutaneous 
efflorescences or ecchymoses. The pupils were regular and reacted normally to light. 
There was no strabismus or photophobia. Nothing abnormal was detected on physical ex- 
amination. The patient was apparently in great pain, cried out a great deal, and moaned 
continually. The sufiering during the next few days was so great that morphine in doses 
of 0.002 gramme {-^ grain) had to be given. This dose had to be increased so frequently 
that it was found that the child took 0.015 gramme (^ grain) before relief was obtained. 




ORGANIC NERVOUS DISEASES. 



703 



Application of ice to the head and spine gave no relief, and 
for a number of days later it was found that there was needed 
CO control the restlessness and pain 0.01 to 0.02 gramme 
(i ^^ i grain) of morphine during the twenty-four hours. 

On the twenty-fourth day of the disease the tempera- 
ture, which had varied from 37.7° to 39.4° C. (100° to 103° 
F.), became normal, remaining so until the forty-seventh 
day. During this time the head was only slightly retracted, 
and the child seemed free from pain, but remained in a 
very listless condition, not speaking, and taking but little 
nourishment or stimulants. He became emaciated, passed 
his urine and faeces involuntarily, and occasionally vomited. 
Nutritive enemata were not retained, but on the forty-first 
day of the disease peptonized milk was retained, and on the 
fortj^-sixth day he was able to take gruel, and at that time 
talked and laughed. 

On the forty-seventh day of the disease a relapse oc- 
curred, the temperature rising to 39.7° C. (103.6° F.). The 
head was rigidly drawn back, the eyes were staring, and the 
pain returned. The symptom of Kernig, which had never 
disappeared entirely, again became well marked. At this 
time I saw the child with Dr. Townsend. On the sixty- 
sixth day of the disease the convulsive movements of the 
left arm and leg, with turning in of the left eye, occurred. 
Several days previous to this relapse a number of sudamina 
appeared on the neck and trunk, and an evanescent ery- 
thematous eruption on the neck and face, lasting only a 
few hours. From the sixty-first to the sixty-sixth day of 
the disease his body was covered with a macular efilores- 
cence, the macules varying in size. Ecchymoses were at 
no time seen, and repeated examinations of the chest and 
abdomen showed nothing abnormal. 

From the seventy-first day to the seventy-third day 
the temperature was again normal, the child took his food 
well, the neck was straight, and his general appearance was 
encouraging. 

On the seventy-fourth day he again had convulsive 
movements, most marked on the left side of the body. The 
head was drawn back, and at noon the next day his tem- 
perature was 39.4° C. (103° F.). The pulse, which during 
the entire illness ranged from 120 to 140 and had previ- 
ously been regular, was now at times irregular and inter- 
mittent. The bowels were constipated at this time. 

After this, although the temperature became normal, 
the child failed rapidly, and there was so much emaciation 
that the finger and thumb could easily encircle his thigh. 

He died quietly on the eighty-seventh day from the 
time of the onset of the disease. 

Through the kindness of Dr. Townsend I am enabled 
to show you his temperature chart (Chart 28) from the tenth 
day of the disease. 

It was very diflScult, indeed impossible, to give a 
prognosis in this case, as at times it seemed as though he 
would recover, and then the temperature would rise again 
and the unfavorable symptoms would return. 





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704 PEDIATRICS. 



LECTURE XXXIV. 

PERIPHERAL NERVES. 

yEURiTis. — Paralysis of the Xew-Borx. — Xeuralgia. 

NEURITIS. — Xeuritis is an inflammation of the peripheral nerves. 
It is accompanied bv pain and tenderness in the affected regions, and in the 
more severe cases by paralysis and atrophy. I shall not dwell upon the 
cases of neuritis of a single nerve-trunk or its branches, which may be 
caused by traumatism, cold, or pressiu'e. or may occm' in the com'se of 
various diseases, b^it shall merely say a few words concerning a definite 
form of this disease, called multiple neuritis. 

Multiple Xeueitis. — In certain constitutional conditions a number 
of neiwes in different parts of the body are affected with nemitis, and this 
constitutes the disease rnultiph' neuritis. 

Etiology, — Multiple neuritis usually occurs in the course of or subse- 
quent to one of the infectious diseases. Of these diseases diphtheria is the 
most common, but it is said to follow scarlet fever and measles. A mild 
form sometimes occms after typhoid fever. At times multiple neuritis is 
produced by drug^s. such as lead, arsenic, or alcohol. It is not a common 
disease among children. The epidemic form of the disease has long been 
prevalent among the Japanese, and is known by the terms kakke and beri- 
beri, but it is cpiite rare in this country, and I have never met witli it in 
children. 

Pathology, — The pathological condition in multiple nemitis is an 
interstitial or parenchymatous intiammation of the nerves. A few nerves 
may be affected, or the distribution may be general. The nerves of the 
special senses, however, are rarely affected, and the nerves of the head and 
face are not usually involved. 

Symptoms. — The onset of the disease may be acute or subacute. It may 
at the beginning present severe symptoms, such as extreme pain, tenderness 
over the nerve-trunks, and fever with an accompanying paralysis. On the 
other hand, the pain in the beginning may be very slight, and the fii*st 
symptoms noticed may be a gradually increasing weakness of the limbs, 
while the tenderness may be found only when especially sought for. There 
may be hyperiesthesia. anaesthesia, numbness, and loss of muscular power. 
After the acute symptoms have passed away the faradic u'ritability is dimin- 
ished : the action of the nerves to the galvanic current is diminished, and 
the reaction of degeneration is present. When the extensors of the leg are 
affecteni there is foot-drop, and when those of the forearm are affected there 
is wrist-drop. The course of the disease is apt to be a long one. and in the 



oegaot:c nekyous diseases. 



705 



Case 327. 



later stages atrophy occurs, while the early hypersesthesia may giye place to 
a more or less marked ansesthesiaj and numbness and various other parpes- 
thesi^e mav occur. In mild cases, where only pain and tenderness exist, the 
knee-jerks are not diminished, and may be even slightly increased, but in 
the more typical cases of the disease they are absent. Contractures and 
spasmodic conditions are absent, the paralysis being flaccid. The tempera- 
ture is apt to be somewhat raised, and is decidedly so at the onset when 
the disease is acute. 

Diagnosis. — The diagnosis is to be made chiefly from poliomyehtis 
anterior, which may simulate multiple neuritis in certain cases ; but in the 
former disease the absence of pain except diu^ing the first few days, with the 
more limited distribution of the paralysis, and the absence of tenderness, 
will serve to distino^uish it from the latter. 

Prognosis. — The prognosis of multiple neuritis is favorable even where 
the disease begins with an acute onset accompanied by delirium and high 
fever, and, although the paralysis may last for many months, the cases 
usually recover. 

Treatment. — The treatment is at first by absolute rest in bed, and 
later with electricity, massage, and strychnine. 

Iodide of potassium is indicated in those cases 
which are caused by lead or arsenic. 

In the subacute cases electricity and massage are 
indicated from the very beginning. 

It is safer to wait until the pain and marked 
tenderness have disappeared before beginning the 
administration of strychnine. 



This little girl (Case 327), eleven years old, represents a 
case of multiple neuritis produced by doses of 1 gramme (15 
minims) of Fowler's solution given three times a day for some 
weeks during an attack of chorea. 

The first symptoms which were noticed while she was 
taking the arsenic were that she vomited several times, but 
this was not supposed to have been caused by the arsenic, and 
the drug was therefore continued. It was next noticed that 
the child was unable to walk. Her limbs appeared to be very 
weak, and there was absence of knee-jerks and ankle-clonus. 
The sensation of the limbs was normal. A few days later she 
-was found to have tender points over various parts of the legs. 
The legs then became atrophied. About a month later tender 
points developed in the arms, and she soon lost the power of 
using her arms, to such a degree that she had to be fed. At 

this time, although the arsenic had been omitted for several days, a large quantity of it 
was found by Professor Wood in the urine. 

You see to-day that she has no remains of the choreic movements, but that she is 
rather stupid, and that there is tenderness on deep pressure over certain points in the 
calves of the legs. She has no headache and no other abnormal symptoms. She is 
being treated with the faradic current daily and with 0.18 gramme (3 grains) of iodide 
of potassium three times a day. Since this treatment was begun, three weeks ago, the 

45 




Multiple neuritis. Female, 
11 vears old. 



706 PEDIATRICS. 

power of grasping has returned, and the arms react somewhat better to the faradic 
current. 

(Subsequent history.) One month later it was found that she could almost support 
herself without assistance. A little later she walked with crutches, and a month later she 
could walk without assistance, but with difficulty. The knee-jerks were still absent. She 
continued to improve, and finally after a number of months recovered entirely. 

This boy (Case 328), who has been brought to the hospital this morning, is an interest- 
ing case of multiple neuritis. 

He is nine years old. He was perfectly well until he was six years old, when he had 
an attack of measles. He was sick for two weeks, and then recovered apparently entirely. 
A week later it was noticed that he became fatigued on going up-stairs, and finally he lost 
the use of his limbs. For a year he walked with the help of a chair. There was simply 
loss of power of motion, but no pain. The appetite was not lost. He at times had slight 
headache. After the paralysis appeared it was noticed that the cervical glands swelled 
at times. The bowels were regular, and there was no trouble with the urine. The limbs 
were somewhat tender on pressure. His temperament was changed, so that he was 
rather fretful. Somewhat later he lost the use of his legs entirely, so that he had to be 
carried. 

He then left his home and went to Florida, and after a few months recovered the 
use of his limbs entirely and became perfectly well. He returned to his home and went to 
school for a month. At the end of that time the symptoms of the previous attack began 
slowly to return, and he finally had to stop going to school. 

On examination he is found to protrude the tongue straight. He has no symptoms refer- 
able to the head. There are red exanthematous patches on the elbows and knees. There is na 
especial atrophy of the legs, but there is a good deal of emaciation of the arms. The arms 
cannot be raised beyond the level of the shoulder. There is some pain in the shoulders 
when the arms are raised for him. There is tenderness on pressure of the shoulders. The 
flexion of the arms is good ; the grasp of both hands is weak, but there is no loss of move- 
ment. The patellar reflexes are absent, and he walks with a peculiar tilt of the pelvis. He 
can stand well with his eyes shut. There is no disturbance of the kidneys and bladder, and 
no proof that the symptoms result from masturbation. No irritation is noticed about the 
prepuce, which, however, is tight. He cannot get up from a sitting posture or when lying 
down. He apparently has lost the power of pushing with his arms. The vertebral column 
is straight, and there is no apparent tenderness. He has never had diphtheria nor any of the 
eruptive diseases except measles. 

The history of this patient and the examination lead me to eliminate hereditary ataxia 
and locomotor ataxia. The rapid improvement which took place in this instance when 
the child was taken away from his home for some months, and the recurrence of the 
symptoms within a month after his return, justify me in suspecting that the cause of the 
disease is a local one connected with the child's home. Of such toxic influences, that from 
lead is the most common and probable. 

PARALYSIS OP THE NEW-BORN.— By paralysis of the new- 
born is meant that form of peripheral paralysis which occurs during the 
delivery, and which, as a rule, affects the face or one of the extremities. In 
this sense it is to be separated from injuries to the brain and spinal cord 
which are produced during the delivery, — in fact, from any paralysis of 
central origin which may occur in intra-uterine life, either before or at the 
time of delivery. 

Etiology. — The cause of this form of peripheral paralysis is most often 
traction made upon the head of the child during delivery, thus producing a 
direct injury to the nerves, or dislocation or fracture of one of the bones, 
resulting in pressure on the nerves. Although this form of paralysis has 



ORGANIC NERVOUS DISEASES. 707 

been known in a number of cases to result from pressure by the forceps 
during the delivery, yet it has also been met with after an apparently 
normal delivery, where the pressure did not seem to be especially severe 
or prolonged. 

Pathology. — When the nerves of the face are affected, the resulting 
lesion is supposed to be from an injury of the facial nerve ; and when the 
arm is affected, the lesion is supposed to be an injury of the brachial plexus 
or of the nerves in the lower part of the neck. When the limbs are affected, 
both arms have been known to be paralyzed ; but, as a rule, the lesion is of 
one arm. 

Symptoms. — A paralysis of this form becomes apparent immediately 
after birth. This is a very important fact to remember, as in this way we 
can differentiate the disease from a paralysis resulting from poliomyelitis 
anterior, which is exceedingly rare in the early months of life, the youngest 
case on record being twelve days old. Where the face is affected, it is due, 
as a rule, to an injury of the seventh nerve, thus producing a peripheral 
facial paralysis. The peripheral form of facial paralysis is distinguished 
from the central in that in the former all three branches of the seventh 
nerve are apt to be affected, while in the latter form only the lower two 
branches are involved. In the peripheral form, therefore, the eye on the 
affected side cannot be closed entirely, causing the condition known as lag- 
ophthalmia, and there is inability to wrinkle the muscles of the forehead 
on the affected side. In facial paralysis of central origin the muscles of 
the forehead are not affected, and the ability to close the eye is but little 
decreased. 

Where the paralysis affects an arm it hangs lifeless by the side, with the 
palm turned backward and the fingers often flexed. The fingers and fore- 
arm may be moved, but the movement of the upper arm to any extent is 
lost. 

Diagnosis. — This form of paralysis is to be diagnosticated from cerebral 
paralysis by the absence of increased reflex irritability and by the distri- 
bution of the paralysis. In the cerebral form all the muscles are affected ; 
in the peripheral form, only individual muscles. It is doubtful whether 
paralyses of spinal origin occur in the early days of life. 

Cases of paralysis of the arm in the new-born should also be diag- 
nosticated from surgical injuries represented by fractures, dislocations, and 
separation of the epiphyses. These are eliminated only by a careful exami- 
nation of the head of the humerus on the affected side, showing the absence 
of crepitus, abnormal mobility, callus, or deformity. 

Prognosis. — The prognosis in cases where the face is affected is very 
good, as the paralysis in these instances lasts but a short time. We must, 
however, be somewhat guarded in the opinion which we give concerning 
them, as in some instances the paralysis does not disappear and the muscles 
of the face are left irreparably injured. 

In regard to the paralysis of the arm, the prognosis is generally un- 



708 



PEDIATRICS. 



favorable, especially if marked improvement does not soon occur, and ordi- 
narily when improvement takes place it is very slow. Most of these cases 

never recover, and partial recovery should not 
Case 329. be expected for a number of years. Shortening 

of the arm is marked in the later history of the 
severer cases. 

We can therefore state that peripheral paraly- 
sis of the new-born when it affects a limb is 
much more serious in its prognosis for complete 
recovery than when it affects the face. 

Treatment. — Electricity and massage con- 
tinuously applied for a number of years is a very 
important part of the treatment of these cases, 
and obviates the atrophy of the muscles from 
disuse, which must necessarily take place to a 
greater or less extent. 




Peripheriil paralysis of the new- 
born. Paralysis of right side of 
face. Forceps delivery. Infant, 2 
hours old. 



Here is an infant (Case 329), two hours old, who has 
a peripheral paralysis of the right side of the face, caused by pressure of the forceps on the 
seventh nerve. 

In this case the closure which you notice of the right eye is produced by the swelling 
of the face and eyelid. You see that the entire right side of the face is affected. 

I have here another infant (Case 330), one year old, who presents the condition of 
peripheral paralysis of the right side of the face. 

Case 330. 




Peripheral paralysis of the new-hom. Paralysis of right side of face. 
Male, 1 year old. 



Infant crying. 



When the infant cries you see that the lines on the right or paralyzed side of the face 
are somewhat obliterated, and that the right eye cannot be closed (lagophthalmia). The 
lines of the left or non-paralyzed side of the face, on the contrary, are deepened, and the 
left eye can be closed. The mouth is drawn to the left. 

The prognosis of this case is bad for complete recovery, and treatment of any kind 
will probably be of no avail, owing to the length of time for which the lesion of the seventh 
nerve has existed. 



OEGAXIC NEEYOUS DISEASES. 



709 



This little boy (Case 331) is two years old. He was healthy at birth, but the labor was 
instrumental. "When he was three days old it was found that his left arm was swollen. 
He was first seen at the hospital when he was seven weeks old. At that time he was able 
to move his fingers and wrists, but held his arm with the elbow straight to the side and the 
hand pronated. He is now, as you see, able to make slight movements of flexion of the 

Case 331. 




Peripheral paralysis of the new-bom. Paralysis of left arm. Male, 2 years old. 

elbow and slight contractions of the deltoid. Under the use of electricity he has been 
showing gradual improvement. He can grasp objects fairly well with his left hand, and 
can flex the elbow completely, and raise his hand and forearm as far as the nipple. You 
see he can raise his right arm with ease to his head, but cannot raise the left hand farther 
than the lower part of the chest. 

It is evidently a case of paralysis of peripheral origin caused by trauma. 

The prognosis in this class of cases is often grave for complete recovery, but, as you 
see, considerable improvement has taken place in this child. 



NEURALGIA. — In contradistinction to the affection of the nerves 
which I have just described as neuritis is a functional affection of the 
sensory fibres of the peripheral nerves, represented by pain and called 
neuralgia. 

Nem-algia is so rare in infancy and early childhood that I shall not do 



710 PEDIATRICS. 

more than refer to it. When neuralgia occurs it may affect very different 
localities, and may be represented by intercostal neuralgia or the various 
milder forms of flitting pains in different parts of the body which so com- 
monly occur in children. 

I have found in most cases of neuralgia that temporary relief from the 
pain can be obtained by the use of phenacetine, and I have never seen any 
contra-indications to using this drug. It can be given in doses of 0.06 
gramme (1 grain) for every year of the child's life up to 0.6 gramme (10 
grains). I am in the habit of guarding against any possible bad effects 
by giving the phenacetine in a little brandy-and-water. 



NERVOUS DISEASES PRESUMABLY ORGAXIC. 711 



LKCTURE XXXV. 

II. NERVOUS DISEASES PRESUMABLY ORGANIC. 

Chorea. — Epilepsy. — Insanity. 

In speaking of the next class of nervous diseases, which I have called 
"presumably organic," it may perhaps be well to explain why I have 
made use of this term. It is because we cannot help feeling that in true 
chorea or true epilepsy there must be some organic lesion, and that it 
merely remains for future investigation to show what the lesion is. AY hen 
this lesion has been determined we can relegate the disease to the organic 
class, or possibly it may be decided that it belongs to the functional diseases. 
Of course there can be but a slight pathological distinction between these 
diseases and those which I have called functional, but their chronic course 
and their serious nature ally them clinically so much more closely to the 
diseases of known organic origin than to the indefinite functional class that, 
for simplicity in teaching, I have decided to se^^arate them from the latter. 

CHOREA. — Chorea is a disease characterized by irregular and invol- 
untary muscular movements without loss of consciousness, and affecting the 
muscles of volition. 

The disease is rare in infancy, but may occur in the early months of 
life. It seldom begins after puberty. It is most apt to begin and is most 
marked in its symptoms during the period of the second dentition, — that 
is, during the period of active growth, from six years to puberty. The 
greatest number of cases is found among the female sex and among those 
who do not receive sufficiently nutritious food. It will be well for you 
to understand clearly that a sharp distinction should be made between the 
disease chorea, with its characteristic choreiform symptoms, and the same 
choreiform symptoms resulting from various diseases, sometimes represented 
by central nervous lesions, sometimes by purely reflex causes. It will save 
you much useless reading of the literature of chorea and much profitless 
discussion as to its etiology and pathology if you will bear this distinction 
in mind. Eliminating those forms of chorea which are due to gross lesions 
of the nervous system, such as the post-hemiplegic and congenital forms, 
we can at once very materially reduce the cases of true chorea. In like 
manner we should separate from true chorea those cases of peripheral irri- 
tation in which the partial choreiform symptoms are evidently reflex and 
can be cured by removal of the cause. Examples of these reflex choreiform 
symptoms are the facial chorea from uaso -pharyngeal irritation and the 
partial choreiform movements occasionally arising from errors of refraction 
and ocular insufliciency. The consideration of these anomalous forms of 



712 PEDIATRICS. 

chorea belongs with the diseases in which they occur, and they should be 
spoken of in connection with the other symptoms of these diseases. 

Etiology. — Chorea can be precipitated by other diseases, such as 
measles, though this, in my experience, rarely occurs except among the 
poorly cared-for. A certain number of cases have so directly followed 
intense fright that we must acknowledge acute mental conditions as a cause. 
The disease Avhich is most frequently associated with chorea is rheumatism. 
The percentage of cases, however, in which this association takes place is 
difficult to determine. This difficulty arises from the want of uniform- 
ity in the reported cases of different observers, due to their different ideas 
as to what constitutes rheumatism. If only the cases of acute articular 
rheumatism are to be classified under rheumatism, very few cases of asso- 
ciated chorea will be spoken of; while if all the flitting aches and pains of 
childhood are considered to be rheumatism, the number of choreic cases 
caused by rheumatism rises to fifty per cent., or possibly more. The truth 
will in the future probably be found to lie in some intermediate number, for 
that in certain cases a close connection exists between chorea and rheuma- 
tism is very evident. The difficulty becomes still greater when we examine 
the relationship between chorea and endocarditis. Of course where there is 
a rheumatic element in the case we should expect a cardiac lesion to arise, 
and to be dependent on the rheumatism. In certain cases, however, we find 
chorea with endocarditis entirely irrespective of rheumatism. This occurs 
to such an extent that in our cases of chorea we should watch for cardiac 
lesions just as carefully as in our rheumatic cases. Heart- murmurs of a 
hsemic nature may occur in chorea as in any other disease of a debilitating 
nature. They should, however, always be looked upon seriously, as possibly 
indicating an insidious form of organic endocarditis, which, instead of being 
evanescent and passing off entirely with the recovery of the chorea, may 
either seriously disable the heart or lead to a fatal issue. A special microbic 
cause for chorea, as for rheumatism, must be thought of, but as yet has not 
been proved to exist. An hereditary tendency to nervous explosions of a 
choreic type has long held a prominent place in the etiology of chorea. In 
my experience, however, it is not very common, unless the children are 
poorly nourished, badly cared for, or exposed to nervous excitement during 
their school life. 

Overtaxing of the central nervous system during the school year has so 
often been shown to result in an attack of chorea in the spring and in a re- 
currence in the autumn on returning to school, that it should be recognized 
in considering the etiology of the disease. Strain of the ocular muscles has 
been considered an exciting cause of chorea. 

Pathology. — There are a large number of cases of chorea in which 
the disease is found to have no apparent pathological lesion. Its symptoms, 
however, show us that the morbid process is located in some part of the 
central nervous system. The lesion, however produced and whatever it is, 
is represented by a profound excitement of the motor centres, presumably 



NERVOUS DISEASES PRESUMABLY ORGANIC. 713 

due to their inanition, and is accompanied by a temporary inability of these 
centres to recover themselves. Many lesions have been described as occur- 
ring in chorea, but in the pure cases (Sydenham's chorea) which I have just 
described, and which really represent the disease, there is no lesion which 
with our present knowledge we can say is characteristic. 

Symptoms. — Chorea may be in its distribution general or partial ; in its 
course acute, subacute, or chronic. In many cases the disease is exceedingly 
mild in its symptoms and of a benign type ; in others it assumes a severity 
which seems to threaten life. I shall presently show you examples of both 
types of the disease. The beginning, though at times sudden, as from 
fright, is, as a rule, gradual, at first a few muscles only being affected. The 
child becomes fretful and impatient, and we must carefully differentiate 
these symptoms from those resulting from bad temper, for which they are 
apt to be mistaken by the family. The clinical picture of the disease is a 
jerky, irregular, involuntary contraction and relaxation of the muscles, apt 
to begin in the fingers, hands, and face. There is an irregular, uncertain 
action of the part affected, and efforts of the will only partly control the 
movements. As the disease progresses, the voluntary control of the muscles 
diminishes more and more, and at times disappears entirely. 

The movements ordinarily cease during sleep, but in severe cases they 
continue during and even interfere with it. At times the child is unable to 
walk, on account of weakness. The speech may become slow and indistinct, 
from the affection of the muscles of the tongue and of the larynx, and even 
mastication and deglutition may become difficult. In very severe cases the 
difficulty in speech may be enhanced by the mental condition, which may 
become impaired, and Avhich is represented by dulness and apathy. The 
tendon reflexes are apt to be lessened in severe cases. The muscles grow 
weak and soft, and there is considerable emaciation. There is usually loss 
of appetite, and the bowels are often constipated. The urine and its urea 
have been found to be increased during the course of the disease. The 
dynamometer usually shows impaired muscular power. In certain cases the 
muscles of the extremities on one side of the body are principally or alone 
affected (hemichorea). These- cases do not differ from the ordinary bilateral 
cases in any way except in this respect. 

In very severe cases there may be involuntary evacuations of the faeces 
and of the urine. The disease is distinct from epilepsy, and there is little 
danger of the patient becoming epileptic unless the disease happens to develop 
in an individual who is predisposed to that condition. 

Prognosis. — Chorea is very apt to show relapses and to recur every 
year for some years. Though often obstinate in the persistency of its 
symptoms, yet it may be said to be self-limited, and, as a rule, to recover, 
provided no complications, such as from cardiac disease, arise. The time 
which elapses before complete recovery is very variable, but well-marked 
cases usually extend over a period of three or four months. Altliough, 
as you will notice, in speaking of the prognosis of chorea I consider it, 



714 PEDIATRICS. 

as a rule, a benign disease, yet we must always look upon it as a serious 
disturbance until we are sure that we are dealing with the usual mild form 
of the affection. As an illustration of how careful we should be to give a 
guarded prognosis in the early stages of acute chorea, I shall mention the 
following case : 

A girl (Case 332), nine years old (Cook and Beale), began to have choreic movements, 
which constantly became worse. Delirium developed, with a slight fever, a rapid and 
feeble pulse, and a quick and interrupted respiration. Death suddenly occurred one hun- 
dred and thirty hours after the onset of the disease. The autopsy revealed extreme anaemia 
of the pons and medulla, but no other changes of note in other parts of the body. 

We must allow that even uncomplicated chorea is a varying disease as to 
the severity of its symptoms and their persistence for a longer or a shorter 
time. We also know that there is a marked tendency to relapse, and that 
the number of relapses varies to a great degree. The length of the attack 
and the response to treatment may differ much. Bearing these facts in 
mind, you will comprehend the rapidity with which certain individuals are 
attacked or the quickness with which they recover. You will meet with 
some cases which recover rapidly under only hygienic treatment, and with 
others which are apparently unaffected by any drug whatever. Where 
heart-murmurs, evidently representing organic disease, appear, you will 
often find cause for wonder in the comparatively slight discomfort which the 
cardiac lesions entail. At times, again, you will be surprised at the rapidly 
fatal course of some cases complicated by cardiac disease, and at their 
uncontrollability by any treatment whatever. 

Treatment. — The disease is variable in its duration whether treated 
by drugs or not. There cannot be said to be any specific treatment with 
drugs for chorea, but of the many drugs that have been used in this disease 
arsenic has, in my experience, been the most beneficial. Arsenic should, 
however, be used with care, and on the appearance of any evidence of the 
physiological action of the drug, such as nausea or oedema of the eyelids, it 
should at once be discontinued. It should not, as a rule, be given in very 
large doses, as cases have occurred in which it has produced a multiple neu- 
ritis of many months' duration. Where any special cause can be found for 
the attack, such as rheumatism, appropriate treatment directed to that cause 
should be employed. It is manifest, however, in the uncomplicated cases 
that our main reliance must be placed on hygiene and food. Fresh air, 
nutritious food, tonics to control the anaemia and general prostration, kind- 
ness, seclusion to secure mental quiet, stimulants if there is much resulting 
weakness, and the bromides for insomnia and over-excitement, are the 
means which I have found most valuable in managing this disease. I 
have seen well-marked cases get Avell in from sixty to seventy days where 
good food and a small amount of stimulant constituted the entire treatment. 

If the attack is very severe, skilled nursing is a very important adjunct 
in the treatment. The child should be protected from harming itself by 



NERVOUS DISEASES PRESUMABLY ORGANIC. 715 

means of the padded bed, and light but well-padded splints to control the 
movements during sleep are indicated occasionally. 

I have a number of cases of chorea to show you. It is one of the most 
common diseases that are seen in the hospital. 

Here is a little girl (Case 333), six years old, who represents one of tlie milder forms 
of chorea. There is no history of nervous or cardiac disease or rheumatism in the family, 
and the child herself has never been sick before. 

Three weeks ago she complained of pain in her left hand and arm, and later the 
muscles of the arm began to twitch. Soon after, the whole body was affected in the 
same way. Somewhat later it was found that the child could not talk plainly, and it 
was with some difficulty that she could feed herself. She seemed nervous and peevish, 
and showed constant irregular incoordinate movements, chiefly of the face, mouth, and 
upper extremities. The legs were slightly affected, and sometimes the muscles of the 
trunk also. There has been no paralysis of the muscles. The eyes have been normal in 
their reaction. 

Since entering the hospital she has been treated chiefly without drugs, and especial 
attention has been paid to giving her a nourishing diet, baths, gentle massage, and rest in 
bed in a quiet corner of the ward. 

On entering the hospital, three weeks ago, a physical examination showed nothing 
abnormal in connection with the heart or other organs. An examination of the urine 
showed it to be normal. 

You see to-day that she is looking very well, and that the incoordinate movements have 
ceased entirely. Marked improvement was shown after she had been in the hospital for 
two weeks, and for the last few days, about the forty-second day from the onset of the 
disease, I have considered her cured and ready to return to her home. 

Here is a little girl (Case 884, page 716), eight years old, whose symptoms are so 
characteristic that we can at once make a diagnosis of chorea. 

I have not been able to ascertain anything concerning the history of this child, except 
that she has been subject to attacks of this nature for some time. There is no history of 
rheumatism, nor- of any other disease. The child seems to be physically well and strong, 
and on examination nothing abnormal is found in any of the organs, with the exception 
of a slight systolic souffle heard distinctly at the apex of the heart and transmitted through 
the axilla into the posterior scapular region. The area of cardiac dulness is not increased. 
The patellar reflexes are increased. There are marked choreic movements of the hands, 
legs, and head. On inspection you see that the limbs are flexed and extended, with irreg- 
ular incoordinate movements, and that there are from time to time the same muscular 
contractions in the face. She shows a certain amount of mental disturbance, characterized 
sometimes by peevishness and sometimes by slyness ; she is dull rather than bright. 

She represents the disease chorea of a moderately severe type, which from its constant 
recurrence and chronic course will probably prove to be very intractable. The prognosis 
as to her mental condition is especially serious, as the probability is that th^ mental im- 
pairment will increase rather than decrease. 

She has been treated with a number of drugs, such as arsenic, quinine, iron, and others, 
none of which seem to be of any beneflt. 

In regard to the mitral systolic souffle to which I have just referred, it is possible that 
it is wholly a functional manifestation. You must always bear in mind, however, that 
there is great liability in cases of chorea of organic cardiac disease developing, and that 
until all signs of cardiac disturbance have disappeared a very guarded prognosis should be 
given as to whether the cardiac disturbance is of functional or of organic origin. 

In a case of this kind, instead of the gradual diminution of the murmur, which would 
seem likely to occur, judging from the very slight evidence of cardiac disturbance present, 
especially as the murmur could be well accounted for by the choreic functional disturbance, 
it is possible that an endocarditis with valvular disease may exist and later produce more 
serious symptoms. 



716 



PEDIATRICS. 



I shall now show you this little girl (Case 335), thirteen years old, who represents one 
of the milder forms of recurrent chorea. 

She had a number of diseases preceding her first attack of chorea. When she was two 
years old she had an attack of diphtheria, when five years old one of measles, when seven 
years old one of scarlet fever, and when eight years old one of rheumatism. 

When nine years old she had her first attack of chorea, which occurred in the spring of 
the year and lasted for a number of months. This was followed in the spring of the next 
year by a second attack. In the spring of the following year she had a third attack of the 



Case 334. 



Case 335. 




Chorea. Female, 8 years old 




Rec 



rtci, fifth attack. Female, 13 years old. 



disease ; at this time the incoordinate movements were not so marked as in the previous 
attacks, but the debility was greater. When she was examined during this attack, it was 
found that the heart, although weak and somewhat irregular, presented no evidence of 
murmurs. The pulse was 84, the temperature was normal, and there were no signs of any 
other disease. She was treated at the hospital, and recovered in a few months. In the 
spring of the next year she had a fourth attack of chorea. At that time nothing abnormal 
beyond the choreic movements was noticed. She was treated with from 0.18 to 0.36 
gramme (3 to 6 minims) of Fowler's solution three times a day, and in a few months left 
the hospital apparently well. 

In the spring of the present year, one year from the beginning of the fourth attack, 
she entered the hospital with a fifth attack, for which she is now being treated. In this 
attack, after using Fowler's solution for a few weeks and not obtaining any especial benefit, 
I have given her iron and nux vomica. She is gradually improving under this treatment. 



NERVOUS DISEASES PRESUMABLY ORGANIC. 717 

and, as you see, has a fairly good color, has a good appetite, and seems quite strong. There 
are some remains of the incoordinate movements, which especially appear when she is 
embarrassed by the observation of the people who are around her. You see she now has a 
slight twitching of the face and hands, and occasionally the hands, and especially the 
thumbs, are drawn inward with an arhythmical movement. 

The prognosis in this case is good. Although she has had five attacks of chorea, no 
organic lesion of the heart, nor any other abnormal condition, has resulted from them, and 
she will probably recover entirel}', and will not continue to have attacks of the disease 
when she is a little older. 

This little boy (Case 336), eight years old, is a case of chorea which I wish merely to 
show you as one in which the treatment by quinine was found to be followed by an increase 
in the choreic movements and to be entirely without benefit. 

The child has always been of a nervous temperament and very studious, and has 
grown rather more rapidly than other children of the same age. He was taken sick one 
month ago, and has been in the hospital two weeks. 

On entering the hospital he had the usual symptoms of chorea, incoordination on using 
his muscles, and difficulty with his speech. His mind was clear, and there was nothing 
abnormal detected about him except a cardiac murmur, apparently h^emic, and consider- 
able general weakness, so that he walked with difficulty. He was at once treated with 
absolute rest and quiet in a room separate from the rest of the patients in the hospital, and 
small doses of iron were administered. His general condition improved gradually but 
slowly during this week, when it was thought advisable to endeavor to hasten his recovery 
by giving him quinine. Sulphate of quinine was administered in doses of 0.12 gramme 
(2 grains) three times a day, with orders to have it gradually increased to 1.2 grammes 
(20 grains) in the twenty-four hours. This treatment was continued during the last week 
until the amount of quinine taken in the twenty-four hours amounted to 1 gramme (15 
grains). 

Under this treatment he has grown steadily worse. The disturbance in speech has 
greatly increased, and he has lost the power of using his arms and legs. His mind is 
clear. There is no vomiting, but he has a certain amount of tinnitus aurium and a slight 
headache. As the deglutition is also beginning to be afiected, I have considered it wise to 
omit the quinine. 

(Subsequent history.) After the quinine had been omitted for twenty-four hours the 
child's general condition was decidedly improved. The treatment with iron was renewed, 
and he gradually recovered, leaving the hospital one month later in apparently good 
health ; the cardiac murmur had disappeared, there were no incoordinate movements, and 
he could speak and use his arms and legs normally. 

This next boy (Case 387), nine years old, has been subject to attacks of chorea /or 
nearly four years. The attacks usually come on in the spring with considerable severity, 
and continue for nearly six months, gradually diminishing in intensity until the symptoms 
are scarcely noticeable. The child has a history of rheumatism, not, however, of a high 
grade. The attack from which he is now suffering began four months ago, and has been 
a quite severe one, so that he has been unable to control the movements of his hands and 
face during the day ; they are, however, quiet at night. 

On entering the hospital a physical examination showed a marked systolic murmur, 
heard most distinctly at the apex and transmitted to the axilla. The area of cardiac dulness 
was not especially enlarged. The urine was normal, and nothing abnormal was detected 
about the child. 

He was at first treated with Fowler's solution, 0.12 gramme (2 minims), three times a 
day. After four days the choreic movements became less marked and the cardiac souffle 
less distinct. Two days later, however, the Fowler's solution had to be omitted, as it 
caused nausea and vomiting. At this time there was a double souffle, heard most distinctly 
over the left third interspace, close to the sternum. A few days later Fowler's solution 
was renewed, but, as it caused gastric disturbance, again had to be omitted, and it was 
found that it could not be given for more than two days at a time without causing puffiness 
of the face. 



718 PEDIATRICS. 

A month later the choreic movements had decidedly lessened and the cardiac murmurs 
disappeared. 

To-day, two months from the time when he entered the hospital, he appears to be free 
from the disease. His muscular movements are natural, though his legs are slightly weak ; 
he has a good appetite, and there are no abnormal symptoms connected with the heart. 

I show 3''ou this case as representing one of recurrent chorea in which arsenic is not 
tolerated, and in which the indications for treatment are chiefly rest, good food, bathing, 
and massage in the beginning, followed later by the administration of some mild form of 
iron, such as the tartrate of iron and potassium. The cardiac disturbance in this case was 
in all probability functional rather than organic, as not only were the cardiac murmurs most 
distinct when the child was weak and anaemic, gradually growing less as he grew stronger 
and the anaemia disappeared, but also on the most careful physical examination I can now 
find no evidence of organic disease. You can therefore consider it a case of recurrent 
chorea with accompanying functional cardiac disturbance. 

This little girl (Case 338), four and one-half years old, in this bed in a quiet corner of 
the ward, is an exaggerated case of chorea. 

Until this attack she had been a healthy, bright, strong child. She had an attack of 
pertussis when she was two and one-half years old, and one of measles when she was three 
and one-half years old. She has never had rheumatism. She began to have choreic move- 
ments of a rather subacute type one year previous to this attack for which she has been 
brought to the hospital. The onset of this second attack was while she was going to school, 
and when she was in fairly good health. The muscles of the mouth and face were first 
atfected, and she seemed to get very much excited when at school, without any apparent 
cause. The symptoms rapidly increased in severity, and she was brought to tbe hospital 
a few days ago. 

I shall not give you the details of this case, as they difier very little from those which 
I have already described to you. I show her to you as representing one of the exaggerated 
forms of chorea. 

The symptoms have increased since entering the hospital, and the muscular move- 
ments are so prominent, even at times occurring when she is asleep, that she has to be 
kept in a padded bed. She is apparently unconscious. She sleeps with the greatest diffi- 
culty, and she has been unable to speak since she entered the hospital. At times the head 
has been slightly retracted, but there has not seemed to be any especial rigidity of the 
muscles of the neck. The area of cardiac dulness is not enlarged. There is a slight cardiac 
murmur, heard most distinctly at the base of the heart. She is being treated with stimulants 
and as much milk as it is possible to make her swallow, but at present she is taking only 
about 473.11 c.c. (1 pint) in the twenty-four hours. 

(Subsequent history.) The choreic symptoms lasted for some weeks, but gradually 
grew less violent, and the child finally recovered entirely. 

An examination of the heart two years later showed that organic disease was present, 
as indicated by the enlargement of the cardiac area of dulness, a mitral systolic murmur at 
the apex, and an accentuated second pulmonic sound. At the time of this examination the 
child was found to be weak and delicate, and was evidently suffering from the efiects of 
organic cardiac disease.) 

In connection with the previous case I shall report to you a case which 
I saw in consultation with Dr. Boardman. 

A boy (Case 339), ten years old, had always been delicate, but had had no special 
disease, such as rheumatism, until six weeks previous to the time when I saw him, when 
he was said to have had an attack of epidemic influenza. He recovered completely from the 
disease in ten days, and seemed as well as ever. Three or four days later he began to show 
symptoms of chorea. These symptoms gradually increased in severity, and finally were 
continuous, except when he was asleep. After he had had the chorea for one week he was 
unable to articulate, and began to have trouble with deglutition. He soon lost the power of 
controlling his limbs, grew very weak, and was confined to his bed. There was considerable 



NERVOUS DISEASES PRESUMABLY ORGANIC. 719 

insomnia. In the second week of the attack the choreic movements became so violent as 
to endanger his falling out of bed. The temperature up to the time when I saw him, in 
the fourth week of the attack, was normal. The pulse varied from 1-10 to 150, and the 
respirations from 35 to 40. 

When I saw him, at the end of the fourth week from the beginning of the chorea, his 
mind was perfectly clear ; he had a little pain in the hands and shoulders, apparently from 
the continual movements. He was unable to articulate clearly. There was difficulty in 
swallowing, and he was considerably emaciated. Nothing abnormal was found in the 
lungs. The heart was beating tumultuously. The area of cardiac dulness was very slightly 
enlarged, but there were no cardiac murmurs. 

The case was apparently one of primary acute chorea without complications. Although 
in many of these severe cases of chorea no evidence of cardiac disease can be obtained on 
physical examination beyond a slight dilatation of the left ventricle, yet some disease of 
the endocardium or valves may often be found at the autopsy. In these cases, however, 
the temperature is, as a rule, raised. In this case the continuous normal temperature and 
the absence of any signs of cardiac disease beyond a slight dilatation from the apparent 
weakness of the ventricular muscles seemed to indicate that it was a case of simple chorea 
without disease of any of the organs. 

Although the child was carefully nursed and remedies of various kinds were employed 
to strengthen the action of the heart and to support his general strength, he failed rapidly, 
and died of exhaustion a few days after I saw him, 

I will now show you this little girl (Case 340), eight years old, whom I have had 
placed in a warm room so that she can be examined naked without harm. 




rlirunia::-: ir:l.r::is. Zi.docar li:is. Cardiac enlargement. Chorea. Female. > years uld. 

The history given to me when the child entered the hospital was that the mother had 
been subject to attacks of rheumatism. This child has not had any especial diseases, with 
the exception of an attack of measles when she was three or four years old, until she had an 
attack of rheumatic arthritis six months ago. At that time she was confined to bed 
with fever, and with pain, tenderness, and swelling in all her joints, especially of the knees 
and fingers. Although she recovered from the acute symptoms of the rheumatism, she has 
since then never been able to use her arms and hands, nor has she been able to walk much, 
I have no record of the condition of her heart during the attack of rheumatism, but so far 
as I can ascertain there was no evidence of cardiac disease prior to the rheumatism. During 
the course of the rheumatism there were no other especial symptoms noticed, except that 
her disposition was evidently much changed and she became peevish and fretful. 

One week before entering the hospital she began to have choreic movements. They 
were moderate in degree, but incessant, A few days later the incoordination of the muscles 
was also noticed when she endeavored to speak or to swallow. There were continual 



720 PEDIATRICS. 

choreic movements of the eyes, face, and fingers, and, although seemingly she could under- 
stand what was said, she was unable to speak clearly. She has been in the hospital ten 
days, and is, as you see, much emaciated. You will notice the incoordinate movements 
of all the muscles of the face, eyes, head, neck, body, and extremities. The peculiar look 
which occurs in these cases, and which can be expressed by embarrassment, is clearly shown 
here. The child feels that she cannot control her muscular movements, and cannot even 
fix her gaze on any object steadily. Although the case is a severe one, the mind is not 
affected beyond a slight degree of hebetude. On physical examination I find that the 
lungs are normal. On examining the cardiac region you notice that the impulse of the 
heart is outside of the mammary line and in about the sixth interspace. On palpation the 
contractions of the heart are found to be of an irritable nature, clearly felt, but not so 
strong as normal. At times there is a feeling as though the ventricular contractions were 
hesitating, and they are of an irregular form, which suggests that the incoordination of 
the other muscles is participated in by those of the heart. On percussion there is normal 
resonance to the right of the sternum and under its upper part as far as the third right 
interspace. There is dulness under the sternum, beginning at the second left interspace, 
extending across to the third right interspace, and involving the lower part of the sternum. 
I have marked the area of cardiac dulness in black. It extends upward to the left of the 
sternum as far as the second rib, then to the left and downward outside of the mammary 
line until it reaches the impulse of the heart in the sixth left interspace. On auscultation a 
murmur is heard most distinctly with the first sound at the apex of the heart, and is trans- 
mitted to the axilla and to both sides of the back. This murmur is transmitted to the base, 
but gradually lessens as the area of the large vessels at the base of the heart is reached. 
Nothing else abnormal is detected on a further physical examination of other parts. 

This is evidently a case where during the course of a rheumatic attack an endocarditis 
in all probability developed. This endocarditis has been followed by enlargement, mostly 
represented by dilatation of the left ventricle. During the course of the rheumatism and 
of the cardiac complication the chorea has developed. 

The prognosis in a case like this must be very guarded. In some instances the disease, 
or rather combination of diseases, grows rapidly worse, and the child dies seemingly from 
exhaustion. In cases of a milder form the child gradually recovers from its chorea and 
from its rheumatism, but is left with an organic disease of the heart from which it never 
recovers. The cardiac disease, however, can in most cases be much benefited by careful 
treatment, especially by rest in bed. In these cases the dilatation grows decidedly less- 
while the heart becomes stronger, and, as the chorea passes away, shows a normal area of 
dulness. 

During the course of a case of this kind we must at any time expect in place of gradual 
improvement a decided increase in the severity of the symptoms. The valvular lesion of 
the heart may become much more extensive, assuming the ulcerative form which is usually 
so fatal. The pericardium may become afiected, and broncho-pneumonia may occur as a 
complication. I shall therefore have to tell the parents of this child that she is in an 
extremely critical condition, and that for some days or weeks it will be impossible to say 
whether she will live or not. 

The treatment of the case is with milk and stimulants. It is impossible for her to 
take solid food, and the milk is with the greatest difficulty introduced into her mouth. I 
will now have the nurse feed her (II., page 721), so that you can see how almost impossible 
it is for her to take the milk in her mouth or to swallow it, although she evidently is de- 
sirous of doing so. 

I have tried various methods of administering the milk and stimulants in this case, but 
have found that the jaws close so spasmodically whenever a spoon is introduced between 
the teeth that the milk is usually spilled before she receives it. The method which I 
have found to be most successful is by this feeding-cup with a rubber nipple fitted to the 
neck of the cup. The rubber nipple is perforated with a large hole. The soft rubber does 
not incite the choreic movements of the jaw to the degree that anything hard would do. 
You see that by a little efibrt of sucking she takes the milk fairly well, though the diffi- 
culty in swallowing continues. The amount of milk which we endeavor to give her in 



NERVOUS DISEASES PEESUMABLY ORGANIC. 



721 



the twenty-four hours, and which I think is sufficient to support her strength until the 
acute stage of the disease shall have passed by, is 14:19. '63 c.c. (3 pints). She is also taking 
about 60 c.c. (2 ounces) of port wine in the twenty-four hours. 

(Subsequent history.) The child remained in about the same condition for the next 
three or four days, when the temperature rose to 38.8° C. (102° F.), and on the following 
day to 40° C. (104° F.), and she complained of pain in the precordial region. On exami- 
nation, in addition to the cardiac murmurs a friction-sound was heard all over the cardiac 
area, but especially in the neighborhood of the left nipple. The area of percussion dulness 
remained the same, and did not extend to the right of the sternum. The child moaned con- 
siderably during the day, and was very restless. The choreiform movements becoming more 




Administration of milk in. a severe case of chorea. 



exaggerated, the port wine was increased in amount and 3.75 c.c. (1 drachm) of infusion 
of digitalis was given once every eight hours. Under this treatment the pulse grew a 
little stronger and the child's restlessness became less. The temperature also fell to 38.6° 
C. (101.5° ¥.), and on the following day to 38° C. (100.5° F.). The pain continued 
during the next few days, and there was a certain amount of diarrhoea. The stimulant was 
increased to 120 c.c. (4 ounces) in the twenty-four hours. The child then became less 
restless, took more nourishment, and slept better. The diarrhoea ceased on the seventeenth 
day from the time when she entered the hospital, and at this time she began to swallow 
better and to speak more distinctly. During the next few days her general condition was 
improved, and she seemed brighter. An examination of the knee-jerks at this time showed 
that the tendon reflex was absent. There was great atrophy of the muscles. The liver 
was found to be somewhat enlarged, and there was slight dulness under the left clavicle, 
hut nothing definite was detected on auscultation. The lymph-glands were enlarged in 
both axillae. The temperature at this time varied from 37.5° to 88° C. (99.5° to 100.5° F.), 
the thirty-first day from the child's entrance into the hospital, and continued at this height 
for the next week. During this time the child remained in about the same condition, but 
grew much weaker and showed more hebetude. 

From the thirty-seventh day from the time when the chorea began the child grew 
much weaker, had incontinence of urine, refused to take her nourishment, and on some 
port wine being given to her vomited. She then was attacked with dyspnoea, which 
caused her to cry out loudly. On examination, dulness and diminisht-d vocal resonance 
were found in various parts of the chest, and a few hours later she died. 

46 



722 



PEDIATRICS. 



These charts (Charts 29 and 30) show the child's temperature from the time when she 
entered the hospital until her death. 























CHART 


29. 






















Days of Disease. 




F. 


8 


9 


10 


11 


12 


13 


14 


15 


16 


17 


18 


19 


20 


21 


22 


23 


24 


25 


26 


27 


28 


c. 


107' 
106' 
105 = 
104 < 
103' 
102= 
101' 
100' 
99 < 

NORM'L 
TEMP. 

98' 
97' 

96' 

95= 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


41.6° 

41.1° 

40.5° 

40.0° 

39.4° 

38.8° 

38.3° 

37.7° 

37.2° 
37.0° 
36.6° 

36.1° 

35.5° 
35.0° 










































































































































/ 








1 


































/ 






/ 


fl 


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J 




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/ 


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V 


1 


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30 


















Days of Disease. 


F. 


29 


30 


31 


32 


33 


34 


35 


36 


37 


38 


39 


40 


41 


42 


43 


44' 


c. 


107' 
106' 
105' 
104' 
103' 
.102' 
101' 
100' 
99' 

lORM'l 
TEMP. 

:; 

96' 
95° 


ME 


M_E 


M_E 


ME 


ME 


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ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


41.6° 

41.1° 

40,5° 

40.0° 

39.4° 

38.8° 

38.3° 

37.7° 

37.2° 
37.0° 
36.6° 

36.1° 

35.5° 
35.0° 


































































































































































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The autopsy was made by Professor Councilman. 

The head was not opened. 

The peritoneum was normal. 

The liver was enlarged, extending 4 cm. (1^ inches) below the margin of the ribs. 

In both pleural cavities there was a considerable accumulation of blood-stained fluid. 
The anterior mediastinum was thickened. 

The pericardium at the apex of the heart was adherent to the left pleura, and about 
this area the tissues were thickened and cedematous. The right lung was slightly adherent 



NERVOUS DISEASES PRESUMABLY ORGANIC. 723 

to the pleura by comparatively late adhesions. The pleura of the lung was smooth, with 
the exception of the adhesions just spoken of. The lymphatics over the surface of the 
pleura were greatly dilated. The upper left lobe of the lung was congested and gave a 
sensation of small nodular masses in it. On section there was a distinct lobular consolida- 
tion throughout the upper lobe. The left lung was of a dark-red color, comparatively 
smooth on section, and somewhat solid. Muco-purulent matter could be squeezed out of 
the bronchi. The chief characteristic of the lung was the extreme dilatation of the inter- 
lobular spaces. The lymphatics all through the lung were visible. In the bronchi there 
was considerable cedematous fluid. The blood-vessels at the base of the lung were free. 
The bronchial glands were enlarged and reddened. 

The left lung was not so adherent as the right. Over the posterior portion of the 
pleura there was a slight fresh pneumonia. The lung was somewhat compressed by the 
exudation of blood, otherwise it was in about the same condition as the right lung. The 
pericardial cavity was obliterated. The adhesions were easily broken down, except at the 
apex, where the pericardium was greatly thickened. Its siirface was covered by a thick 
layer of fibrin and exudation. 

The heart was enlarged. Over its surface was a dense layer of fibrin. At the apex of 
the left ventricle, at a point corresponding to the adhesion of the pericardium, the myo- 
cardium felt soft and had a whitish infiltration. Beside this, corresponding to the intra- 
ventricular septum, there was a line of rather firm, thick, whitish nodules. The interior 
of the right side of the heart contained moderately firm fresh clots. The surface of the 
myocardium on the right side of the heart was pale and soft. Along the free border of the 
auriculo-ventricular valve there were a few fresh vegetations. The left side of the heart was 
dilated, and the ventricle was thickened. The edge of the mitral valve was thickened and 
eroded, and there was distinct loss of substance in the thickened portion of the valve, which 
had irregular and eroded edges. The muscular substance of the heart was pale, with small 
whitish spots beneath the endocardium. These spots were very slightly elevated, and were 
more or less circumscribed. Similar spots could be seen in the cardiac muscles. The sur- 
face of the left auricle was thickened, and beneath the thickened area were numerous small 
whitish points. The aortic valves were intact, save for a few fibrinous deposits at the edge 
of the contact. The beaded row of elevations described on the surface of the pericardimn 
corresponded to the course of the descending branch of the left coronary artery, and was 
probably due to thrombi with suppuration around them along the course of the artery. 

The spleen was enlarged to the size of 10 X 8 X 3^ cm. (4 X 3 X IJ inches), and was 
comparatively soft. Over its surface were a few small adherent thrombus-masses. On 
section the Malpighian bodies were extremely prominent. 

The mesenteric lymph-glands were enlarged and slightly softened. 

The liver was large, the bile-ducts were free, and the gall-bladder was slightly dis- 
tended. The portal vein was free. The surface of the liver was dark red. The lobules 
were prominent, and on section were slightly congested. 

The pancreas was apparently normal. The suprarenal glands were normal. Both 
kidneys were of the same general size and appearance ; in both the cortex was extremely 
pale, and the capsule was easily torn ofi". In the cortex there was a slight diffuse staining. 
The glomeruli were pale, but otherwise showed no change. In the lower ileum there was a 
slight enlargement of the follicles and of Peyer's patches. The glands at the root of each 
lung were enlarged and swollen. The left jugular vein was filled by a rather firm, slightly 
adhesive thrombus-mass, which extended downward into the subclavian vein and across 
this to the superior cava, into which it projected, and on the end there were a few soft fresh 
clots. 

The anatomical diagnosis of this case was, — 

1. Chronic pericarditis and mediastinitis. 

2. Acute ulcerative endocarditis. 

3. Thrombosis of innominate and left jugular veins. 

4. Broncho-pneumonia. 

5. Passive congestion and cedema of lungs. 

6. Adhesions of pericardium. 



724 PEDIATEICS. 

7. Dilatation of interlobular lymphatics. 

8. Acute pleurisy, right side. 

9. Hydrothorax, both sides. 

10. Acute spleen-tumor, 

11. Occlusion of descending branch of left coronary artery. 

12. Acute swelling of bronchial and mesenteric glands. 

Cultures made from various organs showed the presence of streptococci, but not of 
pneumococci. 

EPILEPSY. — Epilepsy is presumably an organic disease of the nervous 
system in which the pathological lesion has not yet been determined. 

The characteristic symptoms are attacks of unconsciousness with or 
without convulsions, with a great liability to a recurrence of these attacks 
through a long period of time. The transient loss of consciousness without 
convulsions which occurs in epilepsy is called petit mal, while the loss of 
consciousness with general convulsive manifestations is called grand mal. 
Convulsions precisely similar to those occurring in true epilepsy may occur 
in organic cerebral disease as the result of external traumatism or from 
other causes ; such convulsions have been termed epileptiform. The term 
Jacksonian epilepsy is applied to localized convulsions which are the result 
of organic cerebral affections. These latter forms must not be confounded 
with true epilepsy. 

It is important that a sharp distinction should be made between the con- 
vulsions of true epilepsy and the many reflex convulsive attacks which come 
from a variety of causes and arise from the hypersensitive condition of the 
infant's nervous system. These reflex convulsions so closely resemble the 
convulsions which occur in epilepsy that the great importance of distinguish- 
ing between the two diseases can hardly be exaggerated. In the infant's 
rapidly growing brain the irritability of certain motor centres is physiologi- 
cally far greater than in later childhood and in adult life. This irritability 
is the source of nervous explosions produced by many causes often slight 
in their nature, and it is impossible to differentiate these explosions by their 
clinical symptoms alone from the convulsive attacks of epilepsy. 

Etiology. — It is usually granted that the initial lesion of true epi- 
lepsy lies somewhere in the cortical motor centres of the brain, and that 
the epileptiform convulsion is an irritation of these centres. True epilepsy 
may of course originate in early infancy, and does so in a large number of 
cases. Whether, however, infantile convulsions may be the cause of epilepsy 
is a very different question. The fact is that we do not as yet know what 
produces epilepsy. The various etiological factors which are usually cited, 
such as fright, injury, and dentition, probably have nothing more to do with 
the production of the disease than to precipitate its development in an indi- 
vidual who is already predisposed to it. Inheritance as a cause of epilepsy 
will presumably, in the future, hold a much less prominent place than has 
been granted to it in the past. 

There is no good reason for believing that reflex convulsions in them- 
selves ever lead to true epilepsy. It is of considerable importance that we 



IfERVOUS DISEASES PRESUMABLY ORGANIC. 725 

should be able to allay the natural alarm of parents by telling them, after 
the convulsions have ceased for a sufficient time to allow us to say that they 
are not epileptic, that there is no chance of their having produced an epilepsy 
which will develop later. 

Symptoms. — Epilepsy may begin in infancy or at any time throughout 
childhood, but a frequent time for its development is at puberty. 

The petit mal may exist in different degrees of severity. In the mildest 
form, which may often pass unnoticed unless the attendants are especially on 
the watch for it^ the child stops for a moment in its occupation, whether 
speaking, eating, or playing, while its eyes become fixed and it assumes a 
vacant expression. This condition may last for only a few seconds, when the 
child assumes its former occupation as though it had never been interrupted, 
and usually is not aware that anything has happened. In other cases this 
condition lasts a little longer, and slight tAvitching of the lower part of the 
face and of the extremities may occur. In other cases, again, the attacks 
are more severe, the child complains of being dizzy, staggers, has slight 
convulsive movements and turns pale, this condition lasting for a minute or 
more, and being quite marked, but without any total loss of consciousness. 
Momentary attacks of staggering sometimes occur alone in place of the 
attacks above described. At times these attacks of petit mal are the only 
manifestations of the disease, but in severe cases they are apt to be accom- 
panied by occasional attacks of grand mal. They may occur as often as 
twenty or thirty times a day, or, on the other hand, they may be noticed only 
once in four or five days, and sometimes they are absent for longer intervals. 

In the grand mal the attacks are of much greater severity. They are 
sometimes preceded for several hours by a feeling of malaise or general dis- 
comfort, but this is not always present. Patients sometimes have notice of 
the sudden onset of the attack, and such notice immediately preceding the 
convulsions and forming part of the attack itself is called the aura. This 
am-a may be of different kinds. It is most commonly a sense of fulness or 
oppression in the epigastrium, from which something seems to rise into the 
throat, and unconsciousness supervenes. It may be, however, a pain or a 
sensation of numbness, tingling, or other form of paresthesia in various parts 
of the body. Sometimes tinnitus is the first symptom. Frequently the 
patient has no warning whatever of the attack, but falls unconscious with or 
without a cry. The face becomes congested, and the eyes usually turn up- 
ward so that only the whites can be seen. After this follows the stage of 
tonic convulsions, which is sometimes so short that it is overlooked. Then 
come the clonic convulsions, which in typical cases are general, although the 
limbs on one side of the body are sometimes more affected than those on the 
other side. The movements of the limbs are apt to be very violent, the 
hands are clinched, the thumbs being flexed on the palms and the fingers 
closed over them. In many ca^es the patients froth at the mouth. In the 
more severe cases the children bite their tongues and pass their urine in- 
voluntarilv. The duration of such attacks is usually five or ten minutes, 



726 PEDIATRICS. 

but one attack may succeed another with little or no intermission. When 
the attacks follow one another in this way for several hours the patient is 
said to be in the epileptic status, and his condition as regards life is very 
serious. After the convulsion ceases the child's breathing becomes sterto- 
rous and the limbs are relaxed. Later, and before consciousness fully re- 
turns, the child often falls into a deep sleep, and on waking has no recollec- 
tion of the attack, but complains only of headache and of mental confusion. 
Attacks often occur in the night, and in this case may be overlooked, the 
only evidence of them being that the child has wet the bed. In certain 
cases where only nocturnal attacks have been present we often have reason 
to believe that the disease has existed for considerable periods before its 
presence was suspected. In some cases in connection with the attacks there 
is a desire to walk or to run, so that the patient must be closely watched. 
In this condition children may walk straight against an obstacle, though 
they are more apt to stop when something comes across their path. Some- 
times they walk or run in circles. 

The cases of paroxysmal running described by Bullard are at times the 
early manifestations of an epilepsy which will develop later, though they 
may also be only the symptoms of hysteria, chorea, and organic cerebral 
disease. 

Epileptic children are liable to bursts of ungovernable anger and vio- 
lence lasting for hours, in which they may tear and destroy things, bite the 
mother or nurse, and are apparently for a time under the influence of illu- 
sions and hallucinations. 

The condition of patients between the attacks is in the lighter cases and 
in the beginning of the disease usually quite normal. As the disease pro- 
gresses, however, there is a tendency to mental impairment, and in the more 
severe cases, in contrast to the lighter ones, we are apt to find some enfeeble- 
ment of intellect, which at times may go on to an advanced dementia. 

It has been considered by some of the most acute observers that those 
cases in which petit mal exists in connection with the more severe attacks 
are more liable to mental impairment than those in which the grand mal 
exists alone. 

Diagnosis. — As the convulsive attacks occurring in epilepsy cannot be 
distinguished clinically from similar attacks due to other causes, we are 
forced to differentiate epilepsy from other diseases by carefully eliminating 
other causes for the convulsions. We must also wait to see whether the 
attacks will continue indefinitely, in which case they are more likely to be 
epilepsy. A very fair illustration of the difficulty which may arise in 
diagnosticating infantile epilepsy is represented by these two infants whom 
I have had brought here to show you. 

This infant (Case 341) was attacked at the age of ten months with general clonic 
convulsions. Previous to that time it had been mentally bright. It was then cutting 
the four upper incisors. One month later it again had a convulsion, the incisors having 
come through the gums. It is now two and one-half years old, and the convulsions have 



XERVOUS DISEASES PRESUMABLY ORGAXIC. 727 

continued, varying in intervals and in severity. The child is now somewhat impaired 
mentally, but there have been no other symptoms of cerebral disease. 

The diagnosis of epilepsy can be made in this case, but this was not warranted at the 
time of its first convulsion, nor indeed for some time afterwards. 

This second case (Case 342), eight months old, is, opportunely for your instruction, 
having a general convulsive attack. You see that it is unconscious ; that the muscles of 
the face and of all the extremities are in active motion ; and that the eyes are turned up. 
This is the third attack that it has had to-day. The lower middle incisors are almost 
through the gum ; the gum is not swollen or tense, and shows no indication for lancing. 
We must therefore look further for the cause of this nervous explosion. There is no evi- 
dence of anything in the ear, and the normal temperature aids us in eliminating the pro- 
dromal convulsions of one of the acute diseases with high temperature. On coming out 
of the convulsion previous to this one there was no evidence from paralysis or stupor that 
any central nervous lesion had occurred. 

So far as the clinical picture is concerned, this may be the beginning of an epilepsy, 
hut the chances in a case like this are always that it is not one of epilepsy. The mother 
now remembers that she gave the infant last evening two or three beans which he managed 
to swallow. The case is probably one of reflex convulsions from gastric irritation. 

(An emetic was given, the stomach was relieved of the beans, and the infant had no 
more convulsions.) 

The diagnosis of epilepsy is made from a continuance of the attacks 
after a considerable period without evidence of any organic disease or 
marked irritation. When the child bites its tongue diu'ing the attack and 
goes to sleep after the convulsion, or when there is temporary mental impau'- 
ment after the convulsion, we have good reason to state that the con^^ilsions 
are due to true epilepsy, especially if no symptoms of organic brain disease 
coexist. 

Epileptic convulsions are easily distinguished from hysterical ones by 
the presence of consciousness in the latter, at any rate to a considerable 
extent. Hysterical convulsions in children are not very common, and 
almost never exist without the presence of other symptoms of hysteria. 

Prognosis. — The prognosis of epilepsy for life is, on the whole, favor- 
able, and epileptics may live for many years. 

As regards cure, the prognosis in cases beginning in early infancy is 
very serious. When the disease begins at the age of ten years or later a 
certain number seem to recover, at least temporarily. Many authorities 
consider that true epilepsy is never cured, yet imdoubted cases exist where 
no convulsions take place for years. 

Treatment. — The child should be treated at once, in order to avoid 
continuous shocks to its nerve-centres. Much benefit results from early 
attention to general hygienic conditions, to diet, and to protection from 
nervous disturbances. 

The management of these cases demands constant watchfulness and tact, 
so as to reo-ulate the surroundino^s of the child in such a wav as to avoid all 
source of irritation and nervous excitement. The diet must be regulated 
according to the especial indications for each patient. Slight gastric irrita- 
tion apparently produces more serious consequences than irritation of any 
other part of the body. A vegetable diet is usually iudicattxl, but where 



728 PEDIATRICS. 

the child does not thrive well on this it is advisable to give a certain amount 
of meat. Eggs are usually well borne. 

The bromides in some form are, in my experience, the most useful 
drugs. It is often advisable in giving the bromides to change from one 
bromide salt to another, a greater effect being thus produced than by the 
constant use of one of them. Efficacious medical treatment depends more 
on the graduation of the doses, on the selection of the time for changing them, 
and on the determination of the intervals for administering them, than upon 
anything else. The best results in using the bromides are obtained by 
diluting the dose with a large quantity of water, 120 c.c. (4 ounces). As a 
rule, bromide of potassium has been found to be the most efficient and active 
of the bromides in cases of epilepsy. In giving the bromides it is well to 
begin with small doses, 0.12 to 0.24 gramme (2 to 4 grains), three or four 
times in the twenty-four hours, for the first year, and to double this amount 
for the second year. The dose should be increased gradually until the 
physiological action of the drug is noticed. 

This treatment, at intervals of one or two weeks, should be carried on 
for long periods, and from six months to a year after the convulsive attacks 
have seemingly ceased. 

This little girl (Case 348), who has been brought to the clinic this morning, is four and 
one-half years old. She was apparently a healthy infant. When she was ten months old 
she began to have convulsions, which were of a clonic type and infrequent at first, bat when 
she was fourteen months old they became more severe and frequent. Since that time the 
convulsions have continued, and at one time she had fifty-four convulsions in forty-eight 
hours. 

She was treated with bromide of potassium, beginning with doses of 0.12 gramme (2 
grains) and gradually increased to 0.3 gramme (5 grains) four or five times in the twenty- 
four hours. Under this treatment the convulsions have become less frequent and her 
general health has much improved within the last year. 

No other symptoms of disease have at any time been detected about this child, and the 
affection is simply represented by convulsive attacks followed by unconsciousness. Although 
the child shows considerable improvement at present, yet the probability is that she will 
never be entirely free from the epilepsy, and that as she grows older, especially as puberty 
is approached, the convulsive attacks ma}^ occur more frequently, and under these circum- 
stances her mind may become more or less affected. 

This child (Case 344), whom I have had brought to the clinic to-day to show to you as 
illustrating an extreme case of epilepsy, is three years old. She was healthy at birth, and 
remained so until she was two months old. At that time she began to have slight con- 
vulsive attacks, the cause of which could not be accounted for on a careful examination. 
During the earlier attacks she looked as if she were frightened. She would then scream, 
and become rigid and unconscious for about fifteen minutes, after which she would sleep 
three or four hours. These attacks occurred at all hours of the day and of the night. 
They have continued at irregular intervals, but are not now so frequent as in the first 
year and a half. During the first year she seemed as bright as any infant of her age, and 
developed normally. 

She has been treated with the bromides, and they seem to have been of some benefit, 
but have not produced a permanent cure. 

During the last year her mental condition has been much affected, and she evidently 
has a permanent injury of the brain produced by her epilepsy. She has never been able 
to sit alone or to bear her weight on her feet. She cannot feed herself, and she understands 



NERVOUS DISEASES PRESUMABLY ORGANIC. 



729 



very little that is said to her. The head is of about the normal size. The face and eyes 
have a vacant expression, and she has to be taken care of as though she were an infant in 
the early months of life. 

In this case there is no history of epilepsy or of any especial nervous disorder in the 
family, nor of traumatism or of any serious disease which could have produced this nervous 
disturbance. We can only say, therefore, that it is a case of chronic epilepsy starting from 
some unknown cause and resulting in permanent idiocy. 

This boy (Case 345) is ten and one-half years old. There is no history of epilepsy or of 
mental disease in his family. He has never had any especial diseases, but for the last six and 
a half years he has been attacked with convulsions occurring about once every three weeks. 
For the past six months the attacks are said to have been more frequent and severe. He at 
times has had as many as five in one week, and some of the attacks have lasted fifteen min- 
utes or more. He states that just before one of these convulsive attacks he feels frightened 
and sick. He then loses consciousness and falls to the ground. The expression of his face 
is rather dull, as though the continued shocks to his nervous system were producing a certain 
amount of mental disturbance. He answers questions, however, readily and intelligently. 
A physical examination shows nothing abnormal. 

Case 345- 




Epilepsy, 63^ years' duration. Petit mal. Male, 10% years old. 



Since entering the hospital, two weeks ago, he has had a number of convulsions and 
has been closely watched, and there seems to be no doubt that the attacks are real and not 
hysterical. The attacks have usually occurred at night, but sometimes also when he has 
been up and about the ward. The attack is usually ushered in by a loud cry, and he is 
then found to be in a state of clonic convulsion. He froths at the mouth, but has not bit- 
ten his tongue. The attacks have lasted for about fifteen minutes, and have then been fol- 
lowed by coma and prolonged sleep for some hours. In addition to the other convulsive 
symptoms there has been much twitching of the face during the attack. The eyelids are 
usually half open, and the eyes rolled upward and inward. The pupils react only slightly 
during the attack, and the eyeballs are not sensitive to touch. As the convulsive seizure 
passes away, the reaction of the pupils gradually returns. During the attack there is no 
apparent sensation produced by pricking with a pin. Some of the attacks are preceded by 
restlessness and an attempt to get out of bed, so that he has to be restrained, and sometimes 



730 PEDIATRICS. 

a general feeling of uneasiness appears to precede the attack. He has been in this condition 
this morning, and has therefore been undressed and put to bed with the clothes simply- 
thrown over him. As you now see him, he is evidently about to have an attack. 

He is very restless, and has thrown back the bedclothes. You see that he now attempts 
to rise from the bed, and that his eyes are somewhat vacant and staring. These premonitory- 
symptoms may simply represent an attack of petit mal, as a number of times they have 
gone no further, or may be the forerunners of a general convulsive attack such as is rep- 
resented by grand mal. 

(This especial attack happened to be represented by the form petit mal, and soon passed 
off without a convulsion.) 

His pulse has been regular, and has varied from 70 to 90. His respirations have been 
about 24 in the minute. His temperature has been normal. 

The treatment of this boy has been with bromide of potassium, but has not been fol- 
lowed by marked benefit. He is probably a case of chronic epilepsy which can never be 
cured, and which, according to Dr. Bullard's opinion after carefully examining him, will 
have to be taken care of in an institution for feeble-minded children. 

This strong, healthy-looking boy (Case 346), seven years old, I have had brought to 
the clinic to-day to show you as another form of epilepsy. There is no history of organic 
nervous disease in the family. He was born after a difficult delivery, and on the following 
day had a number of convulsions, which continued at intervals for several days. They 
were of a clonic general variety, and were apparently relieved by small doses of bromide of 
potassium. During the first year, although the convulsions did not return, he had from time 
to time slight attacks, in which he turned pale and became almost unconscious. These 
attacks, however, lasted for only a few minutes. It is reported that during the first six 
months, although his physical development was fairly normal, he did not notice anything 
and seemed almost blind. After that time, however, his mental condition improved, although 
he seemed a little backward in comparison with other infants of the same age. During the 
first year and a half of his life his left leg seemed smaller than the right and was a little 
shorter, but no especial paralysis was noticed, and by the time that he was three years old 
no difference in the size of the limbs was detected. When he was one year old he was able 
to sit alone. His teeth were cut at the usual time. "When he was two years old the 
measurements of the head showed that it was of about the normal size and the anterior 
fontanelle was closed. Towards the end of the second year he began to talk. When he 
was two and a half years old he had cut all his teeth and was well and strong, had a good 
appetite, and could walk well. He had, however, shown signs of mental disturbance. He 
was fretful, was subject to explosions of temper, and had to be carefully looked after to see 
that he did not hurt himself or the other children in the family. 

When he was four years old he began to have convulsions of a clonic general type, 
occurring at night and ushered in by a scream. During these attacks he frothed at the 
mouth, was unconscious, had stertorous breathing, and after five or ten minutes would fall 
into a deep sleep from which he could not be aroused for a number of hours. On the fol- 
lowing day he would be somewhat dull and fretful, but these symptoms would then pass 
away, and the convulsions would not return sometimes for a number of months. 

As you see him to-day- he is physically well developed. His mental impairment is, 
however, very evident ; his eyes are not bright, he has a rather vacant, idiotic expression, 
and, although he has learned to read, he does not show as much intelligence as his brother 
who is four years old. Physical examination shows nothing abnormal. 

This case illustrates a cerebral injury taking place at birth. This injury has left its 
mark on the brain in such a way that entire recovery will probably never take place. The 
convulsions are evidently epileptiform, — that is, they are caused by an irritation of some of 
the motor centres produced by the original cerebral lesion. 

In a case of this kind treatment by drugs is usually without benefit. The attacks seem 
to be somewhat controlled by the bromides. There has been at times much constipation : 
when the constipation is excessive the attacks are more likely to occur, and it has been 
found that if the bowels are carefully attended to and the constipation thus combated he 
is in a better condition. It is a case in which much benefit can be obtained by mental 



NERVOUS DISEASES PRESUMABLY ORGANIC. 731 

training, and lie should be placed in some institution devoted to the training of feeble- 
minded children or in the hands of some expert in this branch of psychology. 

INSANITY. — Insanity in children is very rtire. In the ordinary forms 
of insanity no definite pathological lesion has been found which would 
account for the symptoms presented. Such changes as have been detected 
come very late in the disease and seem to be secondary. In paretic de- 
mentia, however, we find a special form of cortical interstitial encephalitis. 

Instances of mania and melancholia at times occur. Hallucinations, 
which are a common symptom in the insanity of adults, occur in children 
usually in connection with the delirium of fever, or more rarely with epi- 
lepsy, as I have already described. Insanit}^ is met with in children at any 
age ; it is extremely rare before puberty, but then becomes more frequent. 

The prognosis of insanity in children varies according to its form. 
Acute mania and melancholia are said to recover generally. True paretic 
dementia is never known to recover. 



732 PEDIATRICS. 



IvECTTURK XXXVI. 

III. FUNCTIONAL NERVOUS DISEASES. 

(Organic nature not yet shown.) 

(1) PKOBABLY CENTKAL. 

Hysteria. — Hypnotism. — Catalepsy. — Simulated Diseases. — lNSOLATio]sr. — Con- 
cussion. — Temporary Amnesia. — Temporary Aphasia.— Arrested Psychical 
Deyelopment. — Ketarded Speech. — Headaches. — Yertiqo. — Sensitive Spine. 
— Tetany. — Payor Nocturnus (Central). 

To-day, gentlemen, I shall speak of a class of cases which you are 
liable to meet with interspersed among the patients with definite diseases 
whom you are called to see. 

These cases are called functional, and are represented by either a tempo- 
rary suspension of, or a perverted use of, the normal physiological functions 
of the nervous system. We have at present no sufficient evidence to justify 
us in classifying these diseases as organic. These functional nervous phe- 
nomena play a role of considerable importance in early life, as they occur 
much more frequently at this period than they do in adults. The various 
functions of the nervous system in early life are in the process of develop- 
ment, and are not so perfected as they are in the more mature subject ; in 
fact, they are in a state of unstable equilibrium : hence shocks of various 
kinds easily cause temporary disturbances which, not being grossly organic, 
can pass away after a period of rest. 

This class of functional disturbances may be divided into nervous phe- 
nomena apparently resulting (1) from some affection of the nervous centres, 
and (2) from some irritation of the peripheral nerves. 

I shall first speak of those functional diseases which are supposed to be 
of central origin. Of these hysteria is perhaps the most difficult to differ- 
entiate correctly and to understand, and I shall therefore begin with that 
disease. 

HYSTERIA. — Hysteria is a functional disturbance of the cerebral 
centres represented, according to Mdbius, by a state in which ideas control 
the body and produce morbid changes in its functions. The name is a 
misnomer, but it has been adopted so generally that we must use it for 
the present. 

We know very little about the etiology of hysteria. Well-marked 
instances of the disease occur in early life, usually in the middle and later 
periods of childhood. 

An inherited nervous organization or highly exciting surroundings, com- 
bined with a lack of proper home discipline, appear to present as likely a 



FUNCTIONAL NERVOUS DISEASES. 733 

field for the disease to develop in as any conditions, such as fright, which 
apparently, at times, directly lead to it. 

The mere presence of emotional or imaginative conditions in children 
does not constitute hysteria. For the existence of the disease it is necessary 
to have definite symptoms, either a markedly disorganized mental state, 
paralysis, anaesthesia, or some serious loss of function (amaurosis, deafness, 
dysphagia). 

Symptoms. — The symptoms in this most protean of diseases are innu- 
merable. Convulsions and paralysis are quite common, while dysphagia, 
amaurosis, and anaesthesia are met with only in the very severe cases, and 
are not often seen in America. Ansesthesia is especially interesting as rep- 
resenting a pure type of the disease, and is usually on one side of the body. 
Children perhaps only two or three years of age affected by hysteria will 
sometimes allow themselves to be pricked on the anaesthetic side of the face 
without wincing. 

Hysteria in children as usually seen in America is marked by the emo- 
tional conditions of the child, and by the presence, in many cases, of a fixed 
idea relating to its own physical condition. The child believes that it can- 
not perform certain actions or functions, and hence does not perform them. 
There probably has often been in the beginning some real difficulty or dis- 
turbance of the performance of these functions, such as pain, which has 
passed away or which is not sufficient to produce the present condition. 

The most common symptoms, aside from the mental condition, are 
(1) convulsions, (2) paralysis, and (3) ansesthesia. 

(1) The convulsions are distinguished from those of epilepsy by the 
absence of loss of consciousness. The patient never seriously injures him- 
self in falling, and does not bite his tongue. He does not sleep after the 
attack. 

(2) The paralysis is often of the spastic form, and may be either hemi- 
plegic or paraplegic. In this form the limbs are rigid and the knee-jerks 
are exaggerated. It may, however, be of the flaccid variety, with the 
knee-jerks diminished or absent. It is distinguished from the organic 
forms of paralysis by the normal reaction of the muscles to electricity, by 
the absence of atrophy, by the absence of any affection of the sphincters, 
and at times by the presence of anaesthesia. 

(3) When anaesthesia occurs it is usually irregular in distribution, occur- 
ring in patches, or else it has the same distribution as in cerebral organic 
disease. It is often variable, changing more or less from day to day. 

Although almost any symptom may occur in hysteria, yet the lack of 
uniformity in the grouping of the symptoms, and the combination of symp- 
toms which belong to entirely different diseases, are of great aid in making 
the differential diagnosis from these diseases. 

We sometimes meet with an exao-o'erated hysteria in children. The 
attacks are represented by screaming, running, jumping, and a feeling ol' 
being pulled about; they may last for hours, or for days; their duration, 



734 PEDIATRICS. 

however, is usually long, — at times, with intervals, over a year. No signs 
of organic disease are found in these cases ; they seldom injure themselves, 
and are finally cured by moral influence, change of scene, and good hygienic 
surroundings. 

Hysteria occasionally causes children to present symptoms of serious 
disease of the spine and joints. This most often follows some slight injury, 
but may occur spontaneously. 

Peognosis. — The prognosis in cases of hysteria is, as a rule, favorable. 

Diagnosis. — Generally, the diagnosis is not so diflicult as in adult life, 
because the child is not able to control its sensations of pain and fear so 
completely as is possible with adults. In surgical cases, however, where 
hysterical affections simulate most closely organic disease of the joints, the 
diagnosis is often attended by extreme difficulty. The application of strong 
currents of electricity will usually show that the ansesthesia is not real. 

A complete differential diagnosis of hysteria would occupy more time 
than I can give to the subject, and I have therefore merely outlined the 
general principles by which you are to be guided in diagnosticating these 
cases. 

Treatment. — The treatment of hysteria is to break up at once the 
harmful home surroundings, if such exist, and by means of gentle but firm 
compulsion to make the child understand that its symptoms are unreal. 
The various local symptoms connected with the digestion and general health 
of the child should be carefully treated, as the hysterical symptoms are often 
largely dependent on conditions of this nature. 

This little girl (Case 347), ten years old, is about to leave the hospital, as she has 
recovered entirely from the disease for which she was brought here for treatment. 

The history of the case is that her parents are living and well, and that there are a num- 
ber of other healthy children in the family. This child had always been well until eighteen 
days before she entered the hospital. At that time she complained of headache, and on 
going to school returned feeling sick and apparently unable to speak. She is said to have 
been unconscious at times, to have had spasms, and to have been very restless at night. 
She evidently had had great lack of care in her home life, and had been given only poor 
food. She showed the evidence of this lack of care in the condition of her skin and her 
digestion on entering the hospital. A physical examination showed nothing abnormal in 
connection with the thorax and abdominal organs. The pupils were slightly dilated, but 
were equal and reacted to light. The knee-jerks were decreased. There was no ankle- 
clonus. She was apparently unable to walk, and she lay in bed taking no notice of any- 
thing, but winked her eyes if anything was thrust towards them. Her hearing did not seem 
to be especially impaired. She lay in bed in a very limp condition, with the legs drawn up 
in various positions. Her head kept rolling from side to side, and occasionally was retracted. 
When asleep her head was retracted so as to make nearly a right angle with the body. It 
was difficult to feed her, as she would not swallow. Her temperature was 37.2° C. (99° F.), 
her pulse 66, and her respirations 16. When being examined she cried out a great deal. 

She was given plenty of good food, and in three or four days her condition was much 
improved. She took her food well, but was apparently unable to feed herself. A few days 
later she showed more intelligence, and on being taken up and dressed it was found that 
she could sit alone and could walk a little with support. On beginning to walk she threw 
her legs about wildly, but after being scolded she walked much better. At one time when 
she was sitting quietly in a chair the visiting physician came into the ward, and she imme- 



FU>'CTIOXAL NERVOUS DISEASES. 735 

diatelj allowed herself to slip from the chair and roll onto the floor, hut evidently was care- 
ful not to hurt herself. She at this time cried out a great deal, but stopped when no notice 
was taken of her. She was still unable to speak, and, although she could sit up in a chair, 
apparently noticed nothing. 

Nineteen days after entering the hospital she appeared much brighter, and began to 
take slight notice of what was going on about her. When questioned, she moved her lips as 
if about to speak, but made no sound. She continued to improve slowly, and a few days 
later said "sister," understood what she was told to do, and attempted to do it. She also 
walked three steps without being assisted. Some days later it was found that she would 
repeat almost any word that was said to her, but in a whisper. After this she improved 
rapidly and began to articulate fairly well, but slowly and with an eflbrt. She also spoke 
voluntarily two or three times. She could not walk without assistance, as she would put 
her foot too far forward. She had been very much constipated through the whole attack, 
but at this time the constipation grew less. A definite training of the arms and legs was 
then begun by means of passive movements and massage. Under this treatment she has, 
as you see, greatly improved, and to-day, the thirty-fifth day from the time when she 
entered the hospital, has recovered completely. She speaks and walks, although she is still 
a little awkward. 

I have concluded that this is a case of hysteria, as she has shown no definite symptoms 
of any other disease, and on account of the emotional character of her symptoms since she 
has been in the hospital. 

HYPNOTISM. — Hypnotism is au artificial mental condition which can 
be produced in children as well as in adults. It is supposed to be a tempo- 
rary abeyance of the powers of the higher cerebral centres. In the ordinary 
cases the child is thrown into a condition in which the consciousness of his 
external surroundings is lost. This condition in outward appearance closely 
resembles sleep, but is produced artificially and can be artificially removed. 
Thus, the sensation of pain can be temporarily abolished, at least to a con- 
siderable extent. For this reason it has been supposed that it might be 
useful in the treatment of cases requiring minor surgical operations. It has 
also been advocated by some physicians as a form of treatment in various 
diseases ; but our experience at the Children's Hospital has proved it to be 
inefficient. 

CATALEPSY. — Catalepsy is only a symptom. It denotes a condition, 
apparently of cerebral origin, in which, together with total or partial loss of 
consciousness, the limbs assume a peculiar form of rigidity called icaxi/, and 
remain for a considerable time in any position in which they may be placed. 
It occurs at all ages, but is very rare in childhood. The youngest case that 
I know of is that of a little girl three years old, reported by A. Jacobi. 

The prognosis and treatment are those of the primary disease. There is 
no special treatment for a single attack. 

SIMULATED DISEASES.— On the boundary-line between children 
who evidently are suffering from the need of judicious discipline and those 
who may be said to have the definite disease hysteria, is a class of cases 
in which simulation appears to play an etiological part. These children are 
usually in the later period of childhood, and seem to have such perverted 
functions of their nervous centres as actually to represent pictures of diseases 
which are easily proved not to be present. Deafness, blindness, pains of all 



736 PEDIATRICS. 

varieties, palpitation, dyspnoea, vomiting, spasmodic attacks of various 
kinds, and many other symptoms arise, and, may persist for long periods. 

The best treatment for these cases is at once to show the child that you 
know his symptoms are unreal and of no importance. 

You will remember the boy (Case 348), ten years old, who was brought 
by his mother to my clinic a few months ago with a history of convulsions 
which had been going on for two years, once or twice in a month. He was 
well nourished and robust -looking. The information was elicited from his 
mother that he never hurt himself when he fell down in a convulsion, and 
that the attacks followed attempts to make him do something which he did 
not wish to do. You may remember that I then suggested in his hearing 
that he should be sent to prison, and that he immediately fell on the floor, 
had a violent convulsion, foamed at the mouth, and was apparently uncon- 
scious. I then picked him up and told him that if he ever behaved in that 
way again he would surely be shut up in prison away from his mother. 
He instantly recovered, and has since been a reasonable member of society. 
You must be prepared to meet with all these different phases of nervous 
manifestations in early life, and learn to recognize to which class of nervous 
diseases they belong. 

INSOLATION. — Heat-insolation, or heat-stroke, is a condition ap- 
parently represented by a functional disturbance connected with the cerebral 
circulation and produced by heat. This affection in varying degrees is of 
somewhat frequent occurrence in children, and is supposed to be accom- 
panied by a hyperemia of greater or less intensity of the meningeal blood- 
vessels. It is met with most commonly in the middle period of childhood, 
because at that age the child is most likely to be exposed to the influences 
which produce it. 

The clinical picture of this class of cases is, as a rule, quite characteristic. 
The child has perhaps been playing on a hot summer's day somewhat more 
vigorously than usual, possibly romping with an older child of more highly 
developed nervous resistance, getting intensely excited, and greatly over- 
taxing its muscular strength. It may be that it has been exposed to the 
direct rays of the mid-day sun ; or it may have been playing in some covered 
but heated and stifling place. The nurse of the child, noticing the extremely 
flushed condition of its face and head and its excited, sparkling eyes, takes 
alarm and hurries it to its home. Intense headache soon comes on, and in 
a few hours delirium may supervene. The skin is hot, dry, and reddened ; 
there may be vomiting in the beginning ; the carotids and temporal arteries 
throb perceptibly. The heart's action is violent, and the temperature is 
raised to 38.9°-39.4°-40° C. (102°-103°-104° F.) ; the pulse is much 
accelerated, perhaps 140 to 150, and is full, but usually rhythmical. The 
conjunctivae are congested and the pupils contracted. Photophobia to a 
greater or less degree is almost invariably present. Beyond this there may 
be no symptoms except a slight amount of muscular twitching, and in some 
cases a convulsion may occur if the temperature runs as high as 40°-40.6° C. 



FUNCTIONAL NERVOUS DISEASES. 737 

(104°-105° F.). The temperature, however, in accordance with the rule in 
this disease as in others which occur in children, does not always produce 
the same or equally severe symptoms. Thus, a temperature of 39.5° C. 
(103° F.) may in one individual give rise to marked nervous symptoms, 
while in the next child that you are called upon to see of the same age and 
with the same disease, a temperature of 40° or 40.6° C. (104° or 105° F.) 
may produce no nervous symptoms whatever, beyond possibly a slight 
apathetic condition. Convulsions may occur as a very common form of 
nervous explosion where fever and disturbance of the cerebral circulation 
are present, but, as a rule, this symptom is absent. 

Prognosis. — Be careful as to the prognosis which you give in these 
cases. Although they often simulate closely a beginning meningitis, a disease 
in which the prognosis, as I have already told you, is unfavorable, yet they 
are very amenable to treatment, and should therefore be carefully differen- 
tiated from that disease. In very severe cases the children may, of course, 
die of insolation, as do adults. 

Diagnosis. — The diagnosis from meningitis is based upon the history, 
the milder grade of the symptoms, except the headache, and finally, in 
doubtful cases, the quick recovery and speedy disappearance of the fever. 

Treatment. — The treatment of heat-insolation should be prompt and 
vigorous. A stimulating enema of salt, one teaspoonful to a quart of 
water, should first be given. The child should then be placed uj^on a bed 
protected by a rubber sheet in a cool, darkened room ; a warm mustard 
pack should be applied to the lower extremities, and the neck and chest 
gently sponged with water at 25° C. (77° F.) for fifteen minutes out of every 
hour. Leiter's coil should be applied to the head with water at 5° C. (41° 
F.) ; bromide of potassium should be given, 0.3 gramme (5 grains) every hour 
for four doses ; a little iced milk may be taken if the child cares for it, not 
more than one or two ounces at a time ; and complete rest and quiet for at 
least twenty-four hours are usually indicated. The child should be watched 
oarefully for some days and not allowed to play actively enough to get 
heated. Great care should be taken for the rest of the summer to protect 
the child from the direct rays of the sun, as after one attack the cerebral 
•circulation remains in a very sensitive condition for a considerable period. 

I have found in my notes an account of two cases of this kind occurring 
in my practice, which I shall report to you. 

A boy (Case 349), ten years old, healthy and well developed, was perfectly well on the 
morning of August 20. The weather was hot and sultry. He played unusually hard with 
some older boys for several hours in the sun. He then went into the house at 3 p.m. with 
his fixee and neck intensely reddened. The skin was hot and dry, the blood-vessels were 
throbbing, and there was severe frontal headache. His temperature was 40.5° C. (105° 
r.) ; his pulse was 160, full and bounding, and the respirations natural. He complained of 
photophobia. He was put to bed in a darkened room and the bowels were moved freely by 
an enema of soap and water. His head and neck were sponged with ice- water. At 4 p.m. 
he was slightly delirious, but could be aroused ; his temperature at this time was 40° C. (104° 
P.). Bromide of potassium in doses of 0.3 gramme (5 grains) was given at 4 p.m. and at 

47 



738 PEDIATRICS. 

5 P.M At 6 P.M. the headache was less, and he fell asleep. He awoke at 10 p.m., and the 
temperature was found to he 38.9° C. (102° F.). He then took some iced milk and a dose of 
hromide of potassium. Later in the night the temperature was found to have fallen to 37.7° 
C. (100° F.), and the pulse to he 100. On the following day the temperature was 36.7° C. 
(98° F.), and the pulse 90. He complained of slight headache, hut there was no photophohia. 
He felt weak and drowsy, and was kept in a dark room all day, taking small doses of milk. 

On the following day he felt well, had a good appetite, and was up and dressed. 

On the next day after driving in an open carriage in the sun for an hour he had a 
headache of moderate severity, hut no fever, and was free from headache and perfectly well 
on the following day. 

During the next two or three years, although he did not have any recurrence of a 
severe character, from time to time during the hot weather he showed that his cerebral cir- 
culation was still in a sensitive condition, as slight exposure to the rays of the sun caused 
considerable headache. 

The next instance of this kind was a boy (Case 350), five years and three months old. 
On August 24 the weather was hot and sultry. The boy was perfectly well during the day, 
and was not exposed to any especial excitement or exertion. He went to bed well. The 
night was hot, no air was stirring, and the room in which he slept was very hot, close, and 
oppressive. 

The next morning he awoke at 5 a.m. with severe frontal headache ; he was very 
drowsy, had no appetite, and his temperature was found to be 38.9° C. (102° F.). He was 
kept all day in bed in a cool room. At times he would cry out from the pain in his head. 
His mind was perfectly clear. A dose of bromide of potassium, 0.3 gramme (5 grains), was 
given at 6 p.m. His temperature at that time was found to be 39.5° C. (103° F.) ; the pulse 
was 140, full and bounding. In the night he became delirious and had to be closely 
watched, as he would jump out of bed and cry out with pain in his head. Cold compresses 
were applied to his head during the night, and on the following day the symptoms were 
much relieved. Half a Kochelle powder was given in the morning and repeated in two 
hours. This was followed by a free movement of the bowels. He felt dull and complained 
of headache, but at 6 p.m. the symptoms were much relieved, and his temperature was 
found to be 36.7° C. (98° F.) and his pulse to be 100. On the following day he was 
reported to have had a good night and to have awakened perfectly well. 

For two or three years following the attack he was liable to have attacks of this kind, 
either from undue exposure to the sun or at night if the room in which he slept happened 
to be ill ventilated and hot, 

CONCUSSION. — By concussion we mean clinically a group of symp- 
toms following some physical shock, with its resulting traumatic irritation 
of the nervous centres. I have met with a number of instances of this 
nervous phenomenon. 

One was the case of a boy (Case 351), four years old, who fell from a table to the floor, 
I saw him an hour later, and found that his skin was cool, and his pulse slow, 60, and 
that he was nauseated and had been vomiting. No evidence of traumatic injury or proof of 
an organic lesion could be found. After a few hours the symptoms gradually improved, 
and he was perfectly well on the following day. 

These indefinite symptoms are usually ascribed to the brain as the seat 
of irritation. 

The treatment of a case of this kind is simply by perfect rest and quiet 
in a darkened room, with hot applications to the feet and abdomen, and 
small and repeated doses of stimulants given by enemata until the stomach 
is able to retain them, the treatment being continued until the circulation is 
normal and the pulse strong. 



FUXCTIOXAL NERVOUS DISEASES. 739 

The next instance of this kind was the case of a little girl (Case 352), sixteen months 
old, whom I saw in consultation with Dr. Townsend. 

The child was perfectly well, and was not of an especially nervous temperament. She 
could speak a number of words and could walk. While sitting in her baby-carriage one 
day at the top of a hill, another child took hold of the carriage and pushed it with great 
rapidity down the hill. The carriage was tipped over, and the child was thrown out on the 
sidewalk, apparently striking on her head. She was unconscious when she was picked up. 
but no signs of injury beyond a slight bruise on the right side of the head could be detected. 
There was no vomiting. Her extremities were cold. Consciousness soon returned, and 
nothing abnormal could be detected on a physical examination. The pulse was 120. and 
the temperature 36.6° C. (98° F.). After the accident she had no appetite, and became very 
cross and easily frightened. The bowels were moved regularly, a slight amount of blood, 
however, appearing in the first discharge which occurred after the accident. It was diffi- 
cult to make her go to sleep, and she would wake up screaming and at times not knowing 
any one. For several days she could not make use of the words which she ordinarily did, 
and did not recognize her father, but was afraid of him, while before the accident she 
enjoyed playing with him. She seemed to have the same fear of a number of other people 
in the house, but did not show any symptoms of fear when being examined by Dr. Town- 
send or by me, although we were entire strangers to her. These symptoms continued for 
some weeks, gradually subsiding, and were not accompanied by any other abnormal con- 
dition, such as a rise of temperature. The child recovered entirely. 

The treatment of the case was simply to keep her in a rather dark room separate from 
everybody but her mother. 

I have here to-day a number of instances of other central and fimctional 
diseases to show you. 

As the causes of these nervous manifestations are manifold, and as 
we know nothing about their pathology, I can best describe their symptoms 
and treatment by describing individual instances of the various cases of this 
kind which have come under my observation. 

TEMPORARY AMNESIA. — Here are two cases which belong to a 
class of ner^'ous distiu-bance which is represented by temporary anmesia. 

This child (Case 353), now ten years old, was playing when he was nine years old 
on an asphalt tennis-court with some older boys. One of the boys threw him down on 
the hard court so that he struck the back of his head. He got up, but felt dizzy, so that 
he did not attempt to play any more, but sat looking at his playmates and occasionally 
making foolish remarks. This finally attracted the notice of his companions, who took him 
home. He was put to bed, and seemed drowsy, but did not have any nausea or any other 
symptoms, except that he could not remember anything, even that he was present at the 
wedding of his aunt on the previous day. He articulated plainly and spoke naturally. 
After sleeping for about twelve hours he woke up with his memory perfectly restored, 
except that he had a very dim remembrance of what had happened to him. Since the 
accident his mental condition has been normal, and as you see him to-day he is a bright, 
well-developed boy. 

The probable cause of his amnesia was a physical shock with resulting abeyance of 
function in the nerve-centres connected with memory. 

This next boy (Case 35-4) , thirteen years old. is a case of the same kind. While run- 
ning, about six months ago, he struck his head against a tree. I saw him three hours later. 
He had walked home, but was a little nauseated, and was put to bed. I found that he had 
partial loss of memory and was drowsy, but that he had no especial pain. He was per- 
fectly well on the following day. and is, as you see, an intelligent boy, without mental 
disturbance of any kind. 

TEMPORARY APHASIA.— An instance of suspension of the cerebral function 
connected with the elaboration of words is illustrated by Demme's case (Case 355) of 



740 PEDIATRICS. 

a child six years old, who, previously well and bright, suddenly lost the power of speech. 
This phenomenon occurred during an operation for talipes, which was being performed 
without an ansesthetic. After the operation the child was perfectly well, but was unable to 
elaborate words until the ninth day, when she began to use the one word "mamma" for 
everything that she wanted to say. She then gradually increased her vocabulary until the 
twenty-first day, when her aphasia disappeared entirely, and she developed mentally and 
physically in a normal manner. 

ARRESTED PSYCHICAL DEVELOPMENT.— Arrested psychical 
development is a term used in speaking of an apparent lack of mental 
growth which is sometimes met with in infancy. So far as we know, it is 
a functional and not an organic condition of the brain. Infants with this 
affection develop both mentally and physically for a variable period, per- 
haps five or six months, and then continue to develop physically but cease 
to develop mentally. This condition lasts for a variable period of months, 
when they begin to develop mentally again, and, although for some time 
they are backward in comparison with other children of their age, they 
finally show no trace of an abnormal mental condition. 

Arrested psychical development seems to be rather commonly associated 
with rhachitis, and may also occur in the course of severe illnesses, but 
nothing else is definitely known concerning it. 

RETARDED SPEECH.— At varying periods during the latter part of 
the first year and the beginning of the second year infants begin to make 
their first attempts to speak. By the middle of the second year they are 
usually able to communicate their ideas by means of short, broken sen- 
tences. In the third year most children speak quite plainly, though they 
do not ccrrectly use the prepositions and adverbs until some years later. 
When during the second year the power of speech does not develop with 
the usual rapidity, it is spoken of as retarded speech. 

This lack of power to speak may be from a simple lack of development 
of certain portions of the brain, or from organic or functional cerebral dis- 
turbance. It may also arise from abnormal conditions outside of the brain. 
The cases which are caused by a lack of development may be of congenital 
origin, or may be due to an arrested cerebral development produced by a 
number of causes. These causes are usually connected with some serious 
interference with the cerebral growth, such as a severe illness. The organic 
aphasia is like that produced by some such organic lesion of the brain as 
exists in cases of cerebral paralysis. It may also be connected with the 
condition of idiocy. The functional aphasia I have already described. It 
may be produced by many causes, among others the infectious diseases. A 
child may for a time during a severe illness, and after convalescence has 
been established, apparently be unable to use the words that it was accus- 
tomed to before the illness. I have in a number of cases, however, noticed 
that the child speaks better than it did before the illness. 

Retarded speech may also be caused by such physical defects as disease 
of the ear resulting in deafness, and from such a physical malformation 
of the mouth, palate, or vocal cords as to render articulation impossible. 



FUXCTIONAL NERVOUS DISEASES. 741 

In this connection stammering may be spoken of as a cause of retarded 
speech. 

A\Tien a child of this kind is brought to you to decide why it is unable 
to speak, you should carefully investigate the previous history. In this way 
you can eliminate organic disease of the brain by means of the absence of 
the usual symptoms of such disease, especially hemiplegia, and by ascertain- 
ing that the child has not had any disease sufficiently severe in its character 
to interfere with the development of the centres of speech. After deter- 
mining that the child is not an idiot, you should make a physical exami- 
nation of the ear and mouth. If, on examining the ear, you find that the 
child is deaf, you will at once have a good reason for his not being able to 
speak. Even where young children have learned to speak fairly well, if 
they later becom? deaf from a disease like scarlet fever they are very apt to 
become mute also. Where such lesion of the ear has occiu'red before the 
chUd has learned to speak, he almost invariably is foimd to be a deaf-mute, 
although there may be no defects in articulation or in his mental con- 
dition. It is seldom that any defect in the mouth or throat is found which 
interferes with articulation, except in cases where very extensive lesions are 
present, such as cleft palate, and sometimes enlarged tonsils combined with a 
high-arched palate and a large adenoid grovi:h. The tongue-tie which 
the parents usually consider to be the cause of the retarded speech is 
seldom present. Where no symptom of organic, fimctional, or develop- 
mental cerebral disease exists, where there is no physical deformity, and 
where the child hears well and seems bright and well developjed in other 
ways, you can, as a rule, assure the parents that the speech is merely re- 
tarded and will probably develop later. 

HEADACHES. — When pain in the head occurs in early life it is to be 
regarded more seriously than when it occurs at a later period, as it is more 
apt to indicate some grave central lesion. The various forms of organic 
headache which arise in children can be spoken of best as symptomatic of 
the various diseases in which they occur. 

There also appears to be a type of headache which occurs in the later 
years of childhood irrespective of any disease and often unaccompanied 
by nausea. These headaches, as a rule, are not of serious import, and are 
usually classed under the term functional. They occur irregularly, and may 
be in any part of the head. They are often so severe that the child has to 
lie down. The interv^als between the attacks are variable, and the length 
of the attacks varies from tv\-o or three hours to a day. Of these functional 
headaches the most frequent form in children is that due to anremia. 

Although in many cases headaches are caused by an improper regulation 
of the diet, yet there is evidently some other cause which we do not recog- 
nize in their production, as with exactlv the same diet for many mmiths 
a child will show no symptoms whatever of headaclie. In like mauner, 
although we know that headaches in children may depend upon constipa- 
tion, yet this class of cases occui-s whether constipation is present or not. 



742 PEDIATRICS. 

Migraine also may exist in children, and is characterized by severe pain 
in the head, sometimes unilateral, sometimes bilateral, accompanied by 
nausea, dizziness, and generally vomiting. The attacks occur at irregular 
intervals, and usually last the greater part of a day. They may be brought 
on by apparently slight causes, such as over-fatigue or very mild indiscre- 
tions of diet, in those predisposed to them. These headaches are markedly 
hereditary. 

Although all these forms of headache are ordinarily very intractable 
to cure, especially where no bad hygienic surroundings exist which might 
account for them, and where the child does not lead a sedentary life, yet, 
as a rule, the attacks have a tendency to lessen and disappear as the child 
grows older. 

The treatment of these headaches is usually unsatisfactory, as the attacks 
seem to arise from some functional disturbance which, irrespective ot any 
cause that we can ascertain, resists the best known hygienic and medicinal 
treatment. Strict directions should be given as to exercise and food. A 
change of air and scene is often a valuable adjunct to the treatment. In 
many cases the administration of fluid extract of ergot, as recommended 
by Dr. Russell Sturgis, has proved to be of benefit. I know of no better 
treatment for cases of this kind during the presence of an attack than 
absolute quiet in a darkened room and the use of bromide of potassium or 
bromide of sodium in sufficient doses to produce sleep, or at least to lessen 
the acute pain. 

This boy (Case 356) is thirteen years old. He has usually been strong and well, active 
in his habits, and bright in his studies. When he was nine years old he had a light attack 
of scarlet fever. Up to that time he is said to have been healthy and never to have had 
any nervous disturbance during the dental period. Just before his attack of scarlet fever 
he had a severe headache. At first these headaches occurred only twice a year, but now he 
is attacked by them four times a year. All the headaches have about the same character- 
istics as the one from which he is now suffering. The pain is usually most intense in the 
top of his head, and extends to the front and back. The attacks generally last a week. In 
the second attack which he had, the pain did not last so many days as in the first and those 
which have occurred later, but he was left in a rather weak condition afterwards, so that he 
could not walk. There was no paralysis of the legs. 

Yesterday he went to school as well as usual, but soon began to feel pain in his head, 
and had to return to his home. The headache has continued, and to-day, as you see, he 
cannot sit up, but has to lie down. He has no nausea, his appetite is good, and there are no 
special digestive disturbances, but he has a slightly coated tongue and a slightly raised tem- 
perature. The bowels are regular, and he complains of nothing but such severe pain in his 
head that he has to lie perfectly still. His diet has always been simple, and there are ap- 
parently no direct causes, such as the use of tobacco, to account for the attack. He has 
never shown any delirium, has always been perfectly conscious during the attacks, does not 
complain of any photophobia, and merely wishes to be let alone. 

On examining him to-day you see that his temperature is 36.6° C. (98° F.), and his pulse 
84, a little irregular, but not intermittent. On physical examination nothing of an organic 
nature is detected in the thorax or abdomen. The heart's action is somewhat irregular, and 
there is a slight murmur with the first sound at the apex, and an accentuated pulmonary 
second sound. He has never had rhachitis. He is rather anaemic, but of course is looking 
unusually pale to-day, as he is in the midst of one of these attacks. 

In this case there may be some slight organic disease of the mitral valve, but, as the 



FUNCTIONAL NERVOUS DISEASES. 743 

child is well and strong between the attacks of headache, the murmur may be of functional 
origin. In either case the headaches can scarcely be accounted for by the cardiac disturb- 
ance, and can well be spoken of under the term functional. 

In treating this case small doses of tincture of digitalis are indicated, on the supposition 
that some disturbance in the circulatory organs exists, evidence of which is given by the 
cardiac murmur. 

We should, in examining a case of this kind, before speaking of the 
attack as functional, eliminate other possible causes. One of the most 
common causes in children, but which does not exist in this case, is pain 
caused by a strain of the eyes. In all cases of headache in children the 
cause of which is not evident, a careful examination of the eyes should be 
made, even though there be no symptoms which point to the eyes them- 
selves. 

As an illustration of a class of headaches the cause of which was 
formerly obscure, I show you this little girl. 

She (Case 357) is twelve years old. She has suffered during the past two years with 
almost continuous headache, so that she has had to be taken away from school. 

A careful physical examination of this child made by me two years ago failed to detect 
anything abnormal, except that she was suffering probably from the results of eye-strain. 
"With the exception of the headache she has been well and strong, has had a good color, 
good appetite and digestion, and has simply been incapacitated from stud3dng and reading 
on account of the pain in her head. 

The child was examined by an oculist and was made to wear glasses, i^o benefit 
resulted, and until within a few weeks her parents supposed that she could not be cured. 

Suspecting, however, that the eyes were really the source of the trouble, I referred the 
child to another oculist, who has made a change in the glasses, and the headaches have 
disappeared. 

VERTIGO. — Vertigo at times occurs in children. It is a term applied 
to a condition in which the individual or the objects around him appear to 
be rolling about. It is called subjective vertigo when the patient himself 
seems to be turning, and objective vertigo when it is the surrounding objects 
that appear to move. 

Vertigo has a variety of causes. It may be due to organic cerebral 
diseases, such as tumors of the brain, especially of the cerebellum, and to 
diseases of the ear and of the eye. It may also be due to circulatory dis- 
turbances, as in cardiac disease, and to gastric vertigo, as from improper 
food, also from tobacco and tea. 

This boy (Case 358), thirteen years old, was referred to me by Professor Blake with the 
history that he had had a purulent otitis several years since, but that this had healed three 
years ago, leaving a condition of adhesions and cicatrices with considerable impairment of 
hearing, but with no trouble of the labyrinth nor any symptoms pointing thereto. 

The child was always strong and well until he was seven years old, when he had the 
purulent otitis which Professsor Blake treated. Three years ago he began to have attacks 
of dizziness accompanied by seeing white spots. He at times had nausea, but no feeling of 
spinning round or falling. He has since had this feeling continuously, and lately it has 
rather increased in severity. He has had no other abnormal symptoms, except that he feels 
somewhat weak. He sleeps well, his appetite is fair, and his bowels are regular. He has 



744 PEDIATRICS. 

good hygienic surroundings, does not smoke, and has never' lived in a malarial district. 
He is a close student, and is not fond of active sports. He has never had any headache. 

There is a strong probability that the vertigo in this case is caused by his drinking too 
much tea and by his sedentary life. I shall therefore simply have him stop drinking tea, 
and have told him to ride on horseback every day. 

(Subsequent history.) "Within a few weeks after the active exercise had been begun, 
and the tea had been omitted from his diet, the boy ceased to have attacks of vertigo. 

SENSITIVE SPINE. — Among the nervous symptoms of central origin 
is what is called sensitive spine, a case of which I have here to show you. 

This boy (Case 359) , thirteen years old, previous to one year ago was perfectly well, 
but since that time has complained of headache at times when studying, has lost his appe- 
tite, and has become constipated. He began to complain of his back at the same time that 
the other symptoms developed. The other symptoms have not been especially pronounced, 
but the pain in his back has grown progressively worse, and there is sensitiveness on pressure 
over the spine. 

After I had first seen him and prescribed exercise in the open air and omission of 
school and of study, he improved for a time, and all the other symptoms disappeared, with 
the exception of the sensitiveness of the spine. Although at times this sensitiveness disap- 
peared entirely, yet it has lately returned, and has been just as painful as in the beginning. 

I therefore referred him yesterday to Dr. Lovett, who reports that there are no indica- 
tions for mechanical treatment, that the spine is normal in every respect, and that Pott's 
disease can be positively eliminated. The tenderness of which he complains is one which 
we are accustomed to see in neurasthenic women. The probability is that, owing to his poor 
physical condition and his slight muscular development, his spine has had to depend on the 
ligaments to maintain it erect, that the sensitive condition and the pain are due to the 
strain which is brought to bear on them, and that this will disappear as his condition 
improves. We can therefore provisionally make the diagnosis of sensitive spine from 
debility, and I shall have him treated by massage, gymnastic exercises, and electricity. 
Some of these cases prove very intractable to treatment. 

(Subsequent history.) Within a month after this treatment was carried out the boy 
recovered entirely. 

TETANY. — Tetany is a term which is used to represent tonic intermit- 
tent muscular spasms without loss of consciousness. The condition is simply 
a symptom of nervous irritation, probably of central origin and not pro- 
duced by organic lesions. This symptom is very apt to occur in cases of 
rhachitis, but it may occur in otherwise healthy children when they have 
various disturbances of the gastro-enteric tract. It is also met with in the 
course of many of the acute diseases, such as pneumonia. 

The spasm usually affects the extremities and not the face, and is accom- 
panied apparently by a certain amount of pain. The legs and arms are 
flexed and rigid, the hands and fingers tightly flexed, the thumbs usually 
beneath the fingers across the palms of the hands. In like manner the feet 
may assume various positions of flexion, such as that of talipes equinus or 
that of equino-varus. The length of time which the tetany lasts is very 
varied ; it may be a few minutes or it may be hours or days. 

The symptom in itself is not a serious one, the danger existing in the 
special disease which causes the tetany. 

Tetany is to be distinguished from tetanus by the spasm of the masseter 



FUNCTIONAL NERVOUS DISEASES. 745 

muscles occurring early in tetanus, and by its being absent or occurring late 
where the child is attacked by tetany. 

Cerebro- spinal meningitis is also to be differentiated from tetany by the 
heightened temperature, the severity of the general symptoms, and the con- 
vulsions and opisthotonos, which I have already described as characteristic 
of that disease, while these symptoms are not pronounced in connection with 
tetany. 

The treatment is to be directed to the special cause of the disease in 
which the tetany occurs. Warm baths are indicated for the relief of the 
spasm, and bromide of potassium is the most efficacious drug in cases of 
this kind. 

PAYOR NOCTURNUS (Central). — The night-terrors of children 
may occur from a variety of causes, and should not be considered as one 
disease, but as a symptom of a number of diseases. Any nervous disturb- 
ance, whether central or peripheral, may produce so profound an impression 
on the sensitive cortical cells of the brain that the child's sleep may be 
distm-bed by a cortical irritation. 

The special form of pavor nocturnus ■which may be considered central has occurred in 
this boy (Case 360), six years of age, who has been brought for advice to the clinic this 
morning. He has always been a delicate, thin, pale child, not caring much for open-air 
exercise, but inclined to remain in the house and to be read to or to have exciting stories told 
to him. His appetite is poor. He is mentally bright and precocious. Otherwise he appears 
to be well, and shows no signs of any organic disease. Last evening he was allowed to sit 
up rather later than usual, and a number of terrifying stories were told to him. He went to 
sleep as usual, but in about an hour waked up screaming. He was found sitting up in bed 
looking terrified. His eyes were staring at some invisible object, evidently a picture in his 
brain and not a reality ; he was pointing at this imaginary source of his terror, and kept 
repeating that it was a black dog. It was impossible to pacify him for about ten minutes, 
and he did not recognize his mother during the attack. He then became more quiet ; the 
wild look passed from his eyes ; he recognized his mother, and soon lay down and went 
quietly to sleep. The cause of this attack, which is typical of the central form of pavor 
nocturnus, was evidently undue excitement of the cells of the cortex in a bright, nervous 
child before going to sleep. The treatment of a case of this kind is to accustom the child to 
more exercise in the open air, to prevent his reading anything but the most ordinary and 
simple books, and to have no stories whatever related to him. 



746 PEDIATRICS. 



lecture: XXXVII. 

IV.— FUNCTIONAL NERVOUS DISEASES.— (Concluded.) 

(2) KEFLEX. 

Payor Nocturnus (Peripheral). — Dental Keflex. — Keflex Nystagmus. — Ke- 
flex OF THE Ear. — Keflex of the Larynx. — Paroxysmal GtAsping. — Keflex 
OF the Lung. — Keflex Cough. — Keflex of the Heart. — Keflex of the 
Stomach. — Keflex of the Bladder. — Keflex of the Vagina. — Keflex of 
the Kectum. 

PAYOR NOCTURNUS (Peripheral).— At the last lecture, gentlemen, 
I showed you a case of pavor nocturnus in which the symptoms were evi- 
dently of central origin. To-day I have to show you a little girl three 
years old who also has attacks of pavor nocturnus. 

The child (Case 361), as you see, is robust-looking. She is said to be always well and 
strong ; to have a good appetite ; not to be nervous or excitable ; to be fond of playing out 
of doors, and not to care to have stories told to her. Her mother also states that she is con- 
stipated, and that she has a tendency to overload her stomach. She has had disturbance 
of sleep for some time, and last night she had an unusually severe attack of pavor noctur- 
nus. She had eaten a very heavy supper, and on going to bed she immediately fell asleep, 
but soon began to be restless, to throw herself about, to groan, and to grind her teeth. A 
little later she woke up screaming, and apparently had a certain amount of dyspnoea. She 
did not recognize her mother, but sat up in bed looking very much frightened and clutching 
at her throat. Her mother made her drink some warm water, which produced copious 
vomiting. She then became rational again, recognized her mother, and soon lay down and 
went to sleep. She has no recollection of these attacks on the following day. 

This is evidently a case in which the irritation is of the terminal filaments of the pneu- 
mogastric nerve in the stomach, causing reflex symptoms of the nervous centres to such an 
extent that the child is terrified and feels as though she would stifle. 

It is a case, therefore, of peripheral pavor nocturnus, and should be treated by moder- 
ating the diet and allowing the child to have only a light and digestible supper. You see 
that the two classes of cases are distinct and that their treatment is entirely different. You 
will also often meet with a mixture of both of these forms in which it is not possible to 
make a clear distinction between them. 

I have collected a number of cases to show you which represent some 
other illustrative types of reflex nervous symptoms. 

DENTAL REFLEXES.— The twitching which occurs in children at 
the time when a tooth is the apparent cause of a certain amount of discom- 
fort and fever should be referred to here as a significant illustration of ner- 
vous phenomena from reflex causes. The cases are numerous, but scarcely 
of suflicient importance to report. In certain instances, however, convul- 
sions of a reflex nature occur at this time and cease Avhen the tooth has 
assumed its place above the margin of the gum. I have also met with some 
interesting cases of local oedema arising during the period of dental irritation. 



FUNCTIONAL NEKVOTJS DISEASES. 747 

One of these cases was a male infant (Case 362), fifteen months old, who some months 
previously, while cutting one of the second molars, had an attack of oedema of the hands, 
which was not accompanied by irritation or any other symptom, and which passed oif after 
a few hours. 

This same boy when the canine teeth were about to come through the gums was again 
attacked by oedema of the face. This local oedema, as in the previous instance, disappeared 
quickly. 

At times I have seen a local oedema attacking one eyelid, so that the eye 
could not be closed. 

Although we cannot say that the irritation from the teeth is necessarily 
the cause of these conditions, yet they so often arise during the dental 
period, and not during other periods of childhood, or before the fourth or 
fifth month, that we can at least say that in individuals of an excessively 
nervous temperament the irritation which evidently arises in certain cases 
when the teeth are developing may be sufficient to cause a nervous explosion, 
which in this sense may be spoken of as of dental origin. 

These are only a few instances of the reflex disturbances which occur 
during the period of dentition, and I shall speak of the subject as a whole 
under the heading of difiicult dentition (page 794). 

NYSTAGMUS. — By nystagmus is meant a peculiar rhythmical oscil- 
lation of the eyeballs, usually from side to side. 

It may be produced by many causes. It is sometimes dependent on 
organic disease of the brain, and sometimes it arises from local diseases of 
the eye. In certain cases it is reflex from various peripheral stimuli. 

Nystagmus of reflex origin is not a very uncommon symptom in young 
children. I have notes of two cases, brothers, who during the dental period 
showed this oscillation of the eyeballs with no other symptoms. Complete 
recovery resulted when dentition was concluded. 

This child (Case 363), three years old, has, as you see, nystagmus. She is rhachitic, 
and did not walk until three months ago. She shows no signs of organic disease, and will 
therefore probably recover from the nystagmus when the rhachitis Is cured. 

REFLEX OP THE EAR. — The reflex connection between the roots 
of the teeth and the membrana tympani by means of the otic ganglion pro- 
duces the well-known reflex earache which occurs during the dental period. 
This phenomenon I shall speak of more fully later (page 795). 

REFLEX OF THE LARYNX.— In certain cases reflex symptoms 
occur in the larynx. This condition is usually noted during infancy rather 
than in childhood. The aflection has been called laryngospasmus, and, 
although it is more usual for it to occur in rhachitic children than in others, 
it is not necessarily confined to rhachitis. It is not in my experience a very 
common disease, but when met with it is very characteristic. 

The infant is suddenly attacked by a spasmodic contraction of the 
larynx. This condition may be precipitated by various causes, such as 
fright and excitement. I have also seen it produced by various periplieral 
irritations, such as those of the nose. At times the attack is so severe 



748 PEDIATRICS. 

that the infant becomes unconscious and cyanotic. The attack lasts for only 
a few minutes, and on recovery the infant seems as well as ever. There 
does not seem to be an inflammatory condition connected with this disease, 
and apparently it is purely of a reflex nature. In some cases a crowing 
laryngeal sound will frequently precede and often succeed the more severe 
stage of the attack. 

The prognosis in cases of laryngospasmus is, as a rule, favorable, 
although very weak infants may die in an attack. 

As the infants are usually delicate and of a highly nervous organization, 
the treatment should be directed to improving their general health and to 
protecting them from nervous excitement until they have attained an age 
when their nervous system is less irritable and is in more stable equilibrium. 
During an attack the treatment is to endeavor to produce relaxation of the 
spasm by peripheral irritation elsewhere. This is usually done by shower- 
ing the child on the chest and face with cold water and lightly slapping the 
back. 

Among a number of cases of this kind which have come under my 
notice was this one : 

A boy (Case 364), one year old, had always shown a nervous temperament and had 
had a number of convulsions when he was cutting his first teeth. With the exception of 
a light attack of epidemic influenza, he had been well and strong. Following the attack 
of epidemic influenza, in which the nasal symptoms were prominent, he was left with a 
very irritable naso-pharynx. He then began to have attacks characterized as follows : 

"Whenever the nurse, while giving him a bath, attempted to cleanse his nose, no matter 
how gently, he would immediately gasp, have a catching sound in his breathing, become 
rigid, draw himself back sometimes almost to the position of opisthotonos, become uncon- 
scious and cyanotic, and then after a few seconds the spasm would pass away and he would 
seem perfectly well again. These attacks continued for some months without apparently 
harming him, and they then grew less frequent and passed away entirely. 

Two other cases, in which the attacks were similar to the one which I have just de- 
scribed, were of infants in their second year. In these cases the attacks were usually brought 
on by excitement and when the children were thwarted in anything which they wished to 
do. In addition to the symptoms which I have just described, there was in the younger 
infant a crowing laryngeal sound just as the attack was taking place and for a few inspira- 
tions after it had ceased. 

As additional examples of reflex phenomena of the larynx having their 
origin in the ear may be mentioned the hoarseness which sometimes accom- 
panies the impaction of cerumen in the ears, and which disappears almost 
immediately after the removal of the mass. Professor Blake reports a case 
where a persistent laryngeal cough of several months' duration was immedi- 
ately relieved by the removal of a bead from the external auditory canal. 
These cases, as well as one of reflex cough (Case 368) which I shall presently 
report to you, can be explained by means of this diagram (Diagram 9, 
page 749), which shows the reflex connection between the ear and the larynx. 

The irritation of the sensitive fibres of the auriculo-pneumogastricus 
distributed in the meatus and to the membrana tympani is reflected along 
the motor fibres of the superior laryngeal nerve, exciting in the larynx the 



FUNCTIONAL NERVOUS DISEASES. 



749 



act of coughing by causing contraction of the crico-thyroid muscle. Where 
the original irritant^ either in the meatus or in the membrana tympani, by 
its continued presence involves the vaso-motor fibres associated with the 
auricular nerve, they conduct their impression to the ganglion of the pneu- 



DlAGRAM 9. 



■-a 



lA 


y 


L 


G 




:;;;^ 



-'T 



Reflex connection between the ear and the larynx. A, auditory canal, membrana tympani, and 
middle ear ; B, second ganglion of vagus ; C, first cervacal ganglion of sympathetic ; D, auriculo-pneumo- 
gastrie nerve ; E, sympathetic fasciculus connecting B and C ; F, nervi molles, vaso-motor connection 
with external carotid ; G, external carotid ; H, laryngeal artery ; S, superior larjmgeal nerve ; L, larynx. 

mogastric, and thence it is deflected through a sympathetic fasciculus pro- 
ceeding from it to the first cervical ganglion. This again through the nervi 
molles carries the impression to the external carotid artery, and by its 
branches to the, mucous membrane of the larynx, and as a result of reflected 
vaso-dilator impressions we may have congestion of the vessels supplying 
the mucous membrane of the larynx, and perhaps effusion from these 
vessels. 

The detailed description and an illustrative diagram (Diagram 10) of 
the anatomical conditions underlying these reflex phenomena will be found 
in a later lecture (page 795). 

PAROXYSMAL GASPING-.— This boy (Case 365), eight years old, has always 
"been delicate, and has evidently been ill fed and ill cared for. He is pale and thin, is of a 
nervous temperament, and has been overworked at school. Physical examination shows 
nothing abnormal in either his thorax or his abdomen. 

The attacks from which he now suffers have occurred for the past month, and are 
growing shorter in their intervals and more severe in their character. The child, from being 
in a state of perfect quiet, suddenly becomes cyanotic, rolls his eyes up, stops breathing, 
gasps, and looks as though he were about to die. The attack lasts about half a minute, 
and he is then apparently as well as ever. Since he was brought to the clinic the intervals 
have been about fifteen minutes. The seizure is apparently a reflex irritation of the 
diaphragm, and could be classed under hysteria. These cases respond quite readily to good 
care, well-regulated food, and relief from the duties of school. 

A boy (Case 366), twelve years old, with the following history was brought to me for 
advice : 

He was of a nervous temperament. He was studious, and did not care to play with 
other boys, preferring to remain in the house and read. His appetite was pretty good ; 
hie was pale and rather apathetic. An examination of the thorax and abdomen revealed 
nothing abnormal. 

Three weeks previous to my seeing him he began while sitting quietly in school to have 
paroxysmal attacks of gasping which he could not control. These attacks were of a much 



750 PEDIATRICS. 

milder grade than in the case which I have just shown you, but were quite as frequent. 
They did not occur when he Avas playing out of doors or exercising, and he had never suf- 
fered from palpitation or dyspnoea. 

Treatment with various drugs, such as arsenic, nux vomica, and iron, given at dif- 
ferent times and separately, had no effect upon the paroxysms. Taking the boy out of 
school, preventing him from studying or reading much, and making him go to the gymna- 
sium and ride a bicycle, lessened the attacks in a few months, and he recovered entirely in 
about eight months. 

REFLEX OP THE LUNG.— In young infants pulmonary attacks 
closely simulating the symptoms of asthma occur from gastric irritation of 
the terminal filaments of the pneumogastric nerve. They are evidently 
reflex in their character, and are promptly relieved by treatment of the 
stomach. They are spoken of under the term asthma dyspepticum. In 
cases of this kind it is usually found that the peripheral irritation either 
arises from the too high percentages of the solid constituents of the milk 
which is given to the infant, or is caused by the total amount of milk given 
being too great for the infant's gastric capacity. 

The first symptoms noticed in these cases are the pallor of the infant's 
face, and a slight cyanosis around the mouth. The respirations then become 
quickened, and the infant is evidently in great distress. It becomes cyanotic, 
breathes very rapidly, and often looks as though it were about to die. On 
examining the chest the lung is found to be resonant, and there is nothing 
abnormal on auscultation except roughened respiration and a few sonorous 
rales. 

An emetic will quickly relieve this condition, which disappears as soon as 
the stomach is emptied. The attacks are sudden and often recur. After 
the attack has passed oif, the abnormal sounds heard in the lung are found 
to have disappeared completely, and the infant seems perfectly well again. 

Another class of reflex pulmonary symptoms which has at times come 
under my notice consists of cases in which from some peripheral irritation 
elsewhere marked pulmonary symptoms simulating pneumonia arise. 

This little girl (Case 367), six years old, is an interesting case of this kind. The first 
attack occurred at a time when she was having an exacerbation of an attack of subacute 
purulent otitis media. This happened one year ago, and she is brought to the clinic to-day 
apparently suffering from an attack of the same kind, so that I shall probably be able to 
illustrate its reflex nature. 

As in the first attack, she has a heightened temperature, 40° C. (104° F.), and rapid 
respirations (60 in a minute). The alse nasi are moving slightly, and she shows a certain 
amount of orthopnoea. Her face, as you see, is flushed, and she has a short, dry cough. She 
has a discharge of pus from both ears. On looking at this child you would naturally say 
that she had pneumonia. Evidence of this is given by the temperature, the, respirations, 
the alae nasi, the cough, and the orthopnoea. On examining the lungs, heart, and throat, 
they are found to be normal. The pulmonary symptoms are evidently reflex in their nature, 
as it is believed that in these cases the reflex symptoms are usually produced by the occlusion 
of the Eustachian tubes. 

Now watch the effect of inflating the Eustachian tubes with the air-douche. You see 
that within a few minutes after I have inflated the Eustachian tubes her breathing has 
become normal in rate, 24 to 28 in a minute, the alffi nasi have ceased to move, the cough 
has disappeared, and the child can now lie down with comfort. The temperature will soon 



fu:nctional nervous diseases. 751 

"begin to fall, and in place of the picture of a pneumonia which you saw a few minutes ago 
you see she is assuming the natural condition of a child with slight fever and a heightened 
temperature caused by inflammation of the middle ear. 

REFLEX COUGH. — The nervous connection between the ear and the 
larynx gives rise at times when there is disease of the former, such as an 
otitis media, to a persistent cough which is evidently reflex, and which is 
relieved only by treatment of the ear. A very interesting case of this kind 
was for some time under my care in conjunction with Professor C. J. Blake. 

A little girl (Case 368), four years old, had an attack of measles which was complicated 
by an otitis media. She recovered entirely from the measles, and seemed perfectly well, 
except that the perforation of the membrana tympani had not entirely healed. Somewhat 
later the cough began. Nothing was found to account for this symptom in the throat, lung, 
or larynx, except a slightly reddened appearance of the latter from coughing- The cough 
was intractable to all local treatment until the ear, which had been in the process of heal- 
ing, again showed signs of increased inflammation. Whenever the ear was discharging, 
the cough ceased entirely. When Dr. Blake treated the ear and the discharge grew less, 
the cough began again, and there was an evident reflex connection between the larynx and 
the ear. 

These reflex phenomena continued for some months, the child always coughing when 
the ear got better and ceasing to cough when the ear got worse. Pinally, on the child's 
being taken to Switzerland and having an entire change of air, its general health was much 
improved and the reflex cough passed off*. There has been no recurrence of this condition 
in the following ten years. 

Where there is an irritation in the naso-pharynx a reflex cough often 
occurs, and is best treated by local applications to the pharynx and naso- 
pharynx. It is important for the physician to recognize this class of 
coughs, as he might otherwise be very unsuccessful in treating these cases. 
Manv children are treated with druo^s for a couo;h which is usually ascribed 
to bronchitis, where no physical signs of irritation can be found in the 
lung, larynx, or throat, and where the irritation is in the nose or the naso- 
pharynx. In place of the many drugs usually given in these cases, a simple 
spray in the nose is indicated. 

REFLEX OP THE HEART.— I occasionally meet with cases of ex- 
treme palpitation in children where nothing organic can be detected, and 
where no cause, such as tea-drinking, is discoverable. The children are of 
a highly neurotic temperament, and are usually much influenced by exciting 
surroundiup-s in theii' homes. 



'&" 



As an illustration of this class of cases I will show you this boy (Case 369), ten years 
old, who is subject to fits of great excitement brought on by the most trivial causes, such as 
preparing to go to school or to take a journey. For some hours before the proper time for 
starting comes he is apt to grow more and more agitated, thinking that it must be time to 
start. He will then often be seized with violent palpitation lasting for several hours and 
forcing him to lie perfectly still on his back. At these times his skin will be cool and pale, 
and his pulse weak and in-egular. Nothing abnormal has ever been detected on an exam- 
ination of the heart or any other organ. 

(Subsequent history.) The attacks in this case lasted until he was twelve years old, and 
have never occurred since. 



752 PEDIATRICS. 

REFLEX OF THE STOMACH. — There are a number of reflex con- 
ditions connected with the stomach arising from ditferent causes but repre- 
sented by the same symptom^ vomiting. Instances of this condition are those 
cases of vomiting which arise from irritation of the larynx and pharynx and 
which are cured by local applications made to these parts. There is another 
reflex gastric condition in which the vomiting is apparently caused by shock, 
probablv afl^ecting the abdominal sympathetic ganglia. 

These cases can best be spoken of in detail when I describe the various 
affections of the stomach. I shall therefore merely refer to them here as 
instances of reflex functional disturbance. 

REFLEX OF THE BLADDER.— Reflex spasm of the bladder occurs 
very frequently in young children. I shall consider it under the head of 
incontinence of urine when speaking of diseases of the bladder. 

REFLEX OF THE VAGINA.— There is almost always a direct cause 
to be found for the reflex nervous symptoms which arise from vaginal iiTi- 
tation. One of the most common causes is the ascaris vermicularLs, which 
at times gives rise to extreme and severe symptoms when it has migrated 
from the rectum. In addition to the local irritation, which causes the child 
great uneasiness, so that it cannot sit still and is continually moving its legs 
about, its temperament may be much affected. A child with this trouble 
is apt to be very fretful, to have violent outbursts of temper, to lose its 
appetite, and to grow thin. A case of this kind has lately come under my 
notice. 

A little girl (Case 370), five rears old. had the most extreme vaginal irritation. When 
I saw her she had been affected for several months and was in a very weak condition. At 
times the irritation seemed to be more than she could bear, so that she would lose all control 
of herself, would throw herself on the floor, and would have violent spasmodic contractions 
of the legs. Her sleep was much interfered with, and her whole appearance was that of a 
child suffering from some serious disease. An examination showed that the ascaris ver- 
micularis was the cause of the vaginal irritation, and after a few days' treatment directed to 
expelling this parasite the child ceased to have any irritation and subsequently recovered 
entirely. 

REFLEX OF THE RECTUM.— In certain cases reflex symptoms of 
a most exaggerated type are localized in the rectum. An instance of this 
phenomenon is this little girl, who, you will remember, was brought to the 
clinic several weeks ago. 

She (Case 371) is four years old She has always been remarkably strong and robust, 
and has never had any especial local trouble with the bladder or the rectum. She is, how- 
ever, of an excessively nervous temperament, and is surrounded by exciting influences in 
her home. 

A few months ago she began to have spasmodic contractions of the sphincter ani. 
W hen she attempted to have a movement of the bowels it frightened her, and she would 
clutch at any piece of furniture which happened to be near her and try not to have the 
movement. She would scream and cry out as if she were in much pain. 

An examination under ether showed nothing abnormal in the rectum or sphincter, such 
as from pressure or from lesions, and the condition was apparently that of spasm simply. 

For the last two weeks she has been treated by the daily dilatation of the sphincter ani 



FUNCTIONAL NERVOUS DISEASES. 753 

Tvith bougies, the size gradually being increased. This has been followed by marked 
improvement, and her mother reports to-day that the trouble has passed away. 

(Subsequent history.) The rectal spasm did not return in this case, but the child began 
to have incontinence of urine, from which she is still suffering two years later. 

Another case which came iinder my care and which was a form of reflex connected 
with the anus was a little girl (Case 372), eight years old. 

This child for a whole year was affected by intense irritation in the region of the anus, 
which prevented her from sitting down for any length of time and kept her in a continual 
state of irritability. i!fothing could be detected during this period which caused these 
symptoms. ]S^o trace of intestinal parasites could be found, and nothing abnormal, either 
at the anal orifice or in connection with the bowels, was seen, the skin around the anus 
being in a perfectly normal condition. 

The child was treated with bromide of potassium for several weeks, and recovered 
entirely. 

What I have said concerning the reflex phenomena of infancy and early 
childhood must not be supposed to be a complete enumeration of these 
affections. Thus, various involimtary movements of the head in infants 
sometimes occur, such as sjKi.smus nutans (antero-posterior movements) and 
_gyi'ospasm (rotary movements). 



48 



754 PEDIATRICS. 



LKCTTURK XIKXVIII. 

CONVULSIONS.— TREMOR. 

CONVULSIONS. — Attacks of motor disturbance represented by con- 
tinuous rigidity or contractions of one or more groups of muscles, lasting 
for a variable time and accompanied usually by unconsciousness, are desig- 
nated convulsions. The term convulsion is applied to a symptom, and not 
to a disease. 

Convulsions may be divided, as to their type, into (1) clonic and (2) 
tonic; as to their form, into (1) general and (2) partial; and as to the seat 
of irritation which causes them, into (1) central and (2) peripheral. 

The clonic convulsion is an active spasmodic contraction of the muscles 
followed by immediate relaxation. The convulsions of epilepsy are illustra- 
tive of this type. 

The tonic convulsion is a more or less continued spasmodic rigidity of 
the muscles. This type is seen in tetanus neonatorum. 

The convulsive movements may affect the entire body and limbs, in- 
cluding the face, or they may affect only certain groups of muscles. Thus, 
they may be localized, as of one limb. They may be unilateral or bilateral. 

The seat of irritation which produces the convulsion is very varied. 
Thus, it may be a lesion of the central nervous system or of the peripheral 
nerves ; in the former case the convulsions are spoken of as central, in the 
latter they are termed 7'eflex. Convulsions are much more apt to occur in 
infancy than in later childhood and in adult life, probably because the 
power of inhibition is not developed in the former. Not only, therefore, do 
we meet with convulsive attacks more frequently the younger the individual, 
but, as a rule, we are led to look upon these convulsive attacks as of much 
less import than in the older subject. The reason for this is that the causes 
of reflex convulsions in infancy are innumerable, and, as a rule, they do not 
result seriously, while in older children and in adults convulsions are almost 
always representative of some serious central lesion. Convulsions are in fact 
so common in infancy that they have been compared to the chill which occurs 
in the initial stage of many diseases arising in adults. It is a fact that the 
various acute diseases accompanied by high temperature, such as pneumonia 
and the exanthemata, are very commonly preceded by a convulsion, and 
that a chill is rare under these conditions in infancy. We must, however, 
not be misled by the frequency and comparatively benign character of con- 
vulsions in infancy and by the rule that they are not fatal. The convul- 
sions of infancy may represent j list as serious conditions as they do in later 
life, and we must always look upon them as a grave symptom until we can 
be sure, by eliminating serious organic lesions as a cause, that we are dealing 



CONVULSIONS. 



755 



with one of the common and mild forms of this phenomenon. We must 
remember that the convulsion does not in itself show us whether it is the 
result of serious or of benign disease. The convulsions which occur from 
some organic lesion, such as cerebro-spinal meningitis, may differ in no way 
from those which arise from some simple cause, such as indigestible food. 
It is therefore well to speak of convulsions apart from the diseases in which 
they occur, and which I have already described. 

We are frequently called to see an infant in convulsions where the con- 
vulsion is the first and only manifestation of the disease which is presented 
to us. The infant after a few signs of uneasiness suddenly becomes rigid 
for a second or two, makes a sound as though choking, the eyes turn 
upward and become fixed, there may be strabismus, the skin becomes 
somewhat cyanotic, and then the convulsive movements begin. The eye- 
lids open and shut ; the face and usually the head are drawn to one side ; 
the fingers are clinched ; the arms move up and down, as do also the legs. 
The back may at times be somewhat arched and the head somewhat re- 
tracted. The infant is apt to foam at the mouth to a greater or less extent ; 
it is perfectly unconscious, and the breathing soon becomes stertorous. 
These symptoms after lasting for two or three minutes are followed by 
complete relaxation, an apparent state of coma, and sleep. The child on 
waking may be bright and well, or the convulsion may recur and continue 
for a much longer time, as in one of my cases, where an infant had fifty- 
two con^mlsions in twenty-four hours. There may be involuntary discharges 
of urine and of fseces. 

I have had an infant brought to show you to-day who illustrates very 
clearly the fact that numerous convulsions do not necessarily lead to a fatal 
issue. 

This infant (Case 373), six months old, is well developed, healthy, mentally bright, 
and has not had any convulsions since it was a month old. During the first two weeks of 
its life it had convulsions almost continuously. 

This table (Table 105) gives the hours and intervals of the convulsions from 9 a.m. one 
day till 9 a.m. the next day. The attacks, as a rule, lasted only a few minutes. 





TABLE 


105. 


« 


(Forty-one convulsions in twenty-four hours.) 






Time of Convulsions. 




9 A.M. 


12 Midnight. 


2.42 A.M. 


6.22 A.M 


11.35 " 


12.35 A.M. 


3.18 " 


6.32 " 


3.10 P.M. 


12.40 " 


3.25 " 


7.10 " 


3.50 " 


12.50 " 


3.42 " 


7.40 " 


4 " 


1 Noon. 


4.40 " 


7.52 '« 


4.07 " 


1.25 P.M. 


5.08 " 


8.07 " 


4.28 " 


2 " 


5.20 '' 


8.17 " 


4.40 " 


2.12 " 


5.30 •' 


8.25 " 


5.55 '' 


2.25 " 


5.45 " 


8.35 " 


6.13 " 


2.38 " 


5.55 " 


9.02 " 


11.50 " 









756 PEDIATRICS. 

The most important, on account of their serious nature, are those con- 
vulsions which are of central origin, and I shall therefore first speak of 
this class. Convulsions of this nature may occur in any disease Avhich is 
represented by a high temperature, such as insolation, meningitis, the exan- 
themata, pneumonia, or other diseases. In these cases the convulsions are 
produced either by the action of the high temperature on the motor centres 
of the brain, or by the direct action of the special toxic agent which is 
producing the disease. These convulsions, as a rule, are general, and are 
produced by the diffuse action of the poison. In this class of cases it is 
probable that there is an extremely hypersemic condition of the blood- 
vessels of the central nervous system. The convulsions may also, in con- 
tradistinction to the supposed active hypersemia of the blood-vessels and the 
high temperature, be produced by vascular stasis and a normal or subnormal 
temperature. This form of convulsions may occur in the course of pertussis 
or of cardiac disease. Again, convulsions are supposed to be caused by an 
ansemic condition of the blood-vessels of the brain, such as may arise from 
loss of blood or from exhausting diarrhoea. Such toxic agents as are repre- 
sented by drugs of various kinds, as belladonna, may produce general clonic 
convulsions. Mental disturbance, such as sudden fright, has also been 
known to produce a convulsive attack. In all these classes of cases the 
convulsions may be partial and clonic instead of general, though the rule is, 
owing to the diffuse character of the irritation, that they are general. In 
addition to these convulsions which arise from a diffuse cause are those 
where, a local lesion having occurred in the brain, from morbid growths, 
embolism, thrombosis, hemorrhage, or any other cause, a disorganization 
of a portion of the brain has been produced. As these lesions are, as 
a rule, focal in their distribution, we are apt to have localized convulsions, 
as I have already explained to you in speaking of convulsions in cerebral 
paralysis, with their resulting hemiplegia. 

A number of other diseases can also, by their direct effects, irrespective 
of the temperature which accompanies them, produce convulsions. Thus, 
convulsions occur not uncommonly in the course of nephritis, in which case 
they are usually called ursemic, also in malaria and other diseases. Direct 
pressure from tumors of the brain or from hydrocephalus may in like 
manner cause convulsions of either a localized or a general form. Finally, 
we may have these nervous explosions in epilepsy, such as I have already 
described when speaking of that disease (page 724). 

It will be well to remember that this entire class of central convulsions 
emanates from the brain ; also that where the convulsions are unilateral or 
localized we should suspect a central rather than a peripheral origin. 

The other class of convulsions, which I have spoken of as of peripheral 
origin, and which are called reflex, have so many causes that it would 
scarcely be advisable to attempt to enumerate them all. Convulsions of this 
class may arise from almost any source in infants whose nervous system is 
so easily irritated that the slightest cause may produce a nervous explosion. 



coxTrLSioxs. 757 

Thf disease which most c*jmmuuly gives rise to convulsions of the reflex 
form is rhaehitis. Rhachitic children seem to be predisposed to spasmodic 
anacks of all kinds, and a general clonic convulsion in children ^vith rha- 
ehitis corresponds to the spasmodic contractions in the larynx which occur in 
rhaehitis. and which I have already spoken of as laryngospasmus. 

It is probable that there is no especial lesion in connection with the 
rhaehitis which necessarily gives rise to convulsions, but that all the tissues 
in this disease are especially sensitive to causes which may produce reflex 
explosions. The most common cause of reflex convulsions in infants is 
improper food. Convulsions from this cause arise not only where mani- 
festly indigestible articles are given to yoimg children, but even in infants 
who are being fed frijm the breast. In the early days and weeks of life, 
before the breast has accpiu'ed its normal fonctions connected with elabo- 
rating a milk in which the solids are in proper proportion to each other and 
to the water, it is not uncommon for the infant to have convtilsions produced 
by a disturbance of the mammary function. In cases of this kind it is 
usually foimd that the percentage of the proteids is high, and that the con- 
vulsions will continue imtil this liigh percentage has been lessened, if the 
intant is allowed to contmue to nurse. Whether the teeth of themselves 
during their development are a source of suflicient irritation to produce 
convulsions has been questioned by many observers. It is. however, evident 
that dm-ing the difl:erent periods of dentition reflex con\'ulsions are more apt 
to occui' than when a tooth is not distiu'bing the infant's nervous system. 
In addition to the convulsions arising from improper food in the stomach 
during the dental period, foreign bodies in the intestine, whether in the 
shape of food or in that of intestinal parasites, may cause reflex convulsions. 
Foreign bodies in the nose and in the ear have been known to produce 
convulsions, as also has an inflamed tonsil in the initial stage of a follicular 
tonsillitis. Hot baths are so often given to infants when they are in con- 
vulsions that they should be spoken of as a source of convulsions, for 
they have been kno^vn to produce this result when care has not been taken 
to test the temperatm-e of the bath before the infant is put into it. 

Peognosis. — The prognosis of infantile convulsions must, as you will 
readily tmderstand. vary much in connection with the especial cause. On 
recx)vering from the attack the infant may show signs of some serious 
central lesion, such as paralysis, or may be left apparently perfectly well. 
A single convulsion followed by perfect recovery is of slight consequence, 
but where the convulsive attacks recur frequently and last longer than in 
the attacks which I have just mentioned, the prognosis becomes graver. 
Even though no central lesion be present, continued convulsions may 
bv the shock to the iutaut's vitality- finally cause death from exhaustion, 
or death may occur from spasm of the glottis. We must, therefore, no 
matter what the cause or what the apparent residt of a convulsion may 
be, always look upon it as a grave symptom and endeavor to prevent its 
reem-renee. 



758 PEDIATRICS. 

Treatment. — When you are summoned to treat an infant who is in 
convulsions, you should first see that the bath, in which you usually find 
that it has been immersed, is not too hot, and should order the infant to 
be taken out of the bath before it becomes conscious, or it may be so fright- 
ened as to excite again the reflex spasm. You should quickly examine the 
thorax for pulmonary and cardiac lesions, and should make inquiries as to 
the history of the case, especially as to the infant's diet. The temperature 
should be taken, and you should notice whether the fontanelle is bulging 
or depressed. 

Having obtained this information, you can eliminate quite a number of 
causes for the attack, such as the onset of one of the exanthemata if the 
temperature is normal, and reflex convulsions from food or foreign bodies in 
the nose or in the ear. You can soon determine whether the convulsions 
arise from exhaustion, so that you can proceed at once to order stimulants, 
if necessary, and, if the convulsions continue, to make use of the general 
treatment which is indicated for all forms of convulsions. 

You should be prepared to act promptly, and for this reason you should 
acquire the knowledge which will enable you readily to classify the attack 
under its proper head and thus treat it intelligently. The parents are so 
terrified when a convulsion attacks an infant that it is necessary for the 
physician to be able to inform them as soon as possible whether or not the 
convulsion is injurious. In order to aid you in differentiating the various 
causes of convulsions from each other I have prepared this table (Table 
106). 

TABLE 106. 

Infantile Convulsions. 
Central. Peripheral (Reflex). 

I. Diseases with high temperature. Ehachitis. 

(Insolation, meningitis, the exan- Food, 
themata, pneumonia, and others.) Intestinal parasites. 

II. Diseases accompanied by vascular stasis. Dental irritation. 

(Pertussis, cardiac disease, tumors, Foreign bodies in the ear and nose, 
hydrocephalus.) Hot baths. 

III. Diseases characterized by anaemia and Mental disturbance, such as fright, and 
exhaustion. numerous other causes. 

(Loss of blood, diarrhoea.) 
lY. Various toxic causes, such as drugs, 
or uraemia 
(Belladonna, nephritis.) 
V. Organic central lesions. 

(Cerebral paralysis, or any other lesion 
of the brain.) 
VI. Presumably organic disturbance of the 
brain. 
(Epilepsy.) 

The treatment of infantile convulsions should be directed to the especial 
cause of the convulsion. In general, however, as often when the convulsion 
is present it is impossible to determine whether it is of central or of periph- 



coxvuLsioxs. 759 

eral r.rioin. it bec<:imes necessary to endeavor to contrr»l the attack at once. 
For this jjurp^jse in all f.jrnis of cr.nvnlsi-jns the inhalation of ether in small 
amrjimts. and tlie emptying of the bowels by means of enemata, are indi- 
cated. AVhere the cc'nvnlsions are of a very severe type, continuing with 
perhaps intermissions of only a few minutes, and the infant's life is evidently 
in danger frijm the continu(?us shocks Avliich are taking place in its nervous 
system, a rectal injec-tion of 0.6 gramme (^10 grains) of bromide of potassitim 
and 0.3 gramme • o grains) of hydrate of chloral in 30 c.c. (1 oimce) of warm 
water, repeated if necessary every hour for three or fotu' doses, is indicated. 
If the convulsions still continue and a fatal issue is anticipated, a subcti- 
taneous injection of sulphate of mijrphine. Ijeginning with 0.001 (-^ grain), 
should be tried. 

In mo-t case- ol' infantile ccmvulsions. of whatever form, the warm bath 
at a temperature of not over 37.7' C. 1 10<)" F. ) can be used, for, althotigh it 
is not in any sense curative, it tends to quiet the nervous excitability and 
to lessen the muscular strain produced Ijy the contintiotis spasmodic muscular 
contractions. The class of cases in which this is contra-indicated are those 
which are cau-ed by a L:iss of blond, an autemie condition, diarrhoea, and 
cardiac disease, and those in which venous stasis exists with a lowered 
temperature. In these cases stimulants are indicated. 

In th'jse cases which are symptr)matic of the diseases which I have 
already spoken of as accompanieel by high temperatiu^e, the application of 
cold to the head and the administration of the bromides are indicated. 

The treatment of convulsiiDus caused by the other diseases which I have 
enumerated is simply sympt^jmatic while the con^iilsions continue, and later 
the proper care of these diseases. All the reflex convulsions from various 
causes are treated in like manner symptomatieally and by the removal of 
the especial cause. 

I have already shown you an infant (Case 342) in clonic con^^ilsions, 
and described to yon the characteristics of the attack, while speaking of 
epilepsy (page 727). 

I have here a few cases which may be of interest in this connection for 
you to see. 

This little girl (Case 374) is six and one-half years old. She was healthy at birth, and 
has never had any disease. For the last three years she has from time to time had a con- 
vulsion, clonic in type. "When in the convulsions she does not bite her tongue. The first 
convulsion occurred when she was three years old ; the next when she was four years old ; 
the next when she was four and one-half years old : and the last one when she was five 
years old. 

As all these convulsions have apparently been produced by the same cause, it will 
only be necessary to describe them in a general way. They have been characterized by 
sometimes continuing much longer than is usual in infantile convulsions, one of them 
having lasted for one hour and a half, during which time the hands were clinched, the eyes 
were rolled up. and the entire body and limbs were convulsed. Previous to each attack the 
child for a number of days has had indefinite symptoms which she could not describe 
accurately, connected with the abdomen and accompanied by a feeling of weakness and 
siisht muscular twitehins:. 



760 PEDIATEICS. 

At the time of the earlier attacks her mother found that these symptoms could be dis- 
sipated and apparently a convulsion prevented from occurring by giving her a dose of 
castor oil about once a week. After the third convulsion she passed a lumbricoid worm. 
From that time whenever she showed the premonitory symptoms of a convulsion she was 
treated with santonin followed b}^ a cathartic, a lumbricoid worm was each time passed^ 
and the symptoms disappeared. When she was five years old she was thoroughly treated 
for these lumbricoid worms with santonin, and after a large ascaris had been passed the 
nervous symptoms ceased entirely. The child has now not had a convulsion for over a 
year. There has been no reappearance of the worms. 

This child represents the class of cases which I have described when speaking of 
reflex convulsions, the cause of the peripheral irritation evidently being an intestinal 
parasite. 

I have here an infant (Case 375), thirteen months old, whose nervous system has 
always been in so irritable a condition that the slightest cause was sutficient to produce a 
convulsion. 

"When he was eight months old he had an attack of pertussis, and during the coui*se of 
the disease he had a number of convulsions. At one time when the pertussis was at its 
height he had from fifteen to sixteen convulsions within thirty -six hours, each of them 
lasting from five to ten minutes. 

When the first teeth began to press upon the gums he occasionally had a convulsion. 
In addition to the general muscular spasms he had nj^stagmus of the right eye. For 
the last two or three months he has had no convulsions, and the nystagmus is much less 
noticeable. 

This boy (Case 376), four years old, has from time to time had convulsions, which, so 
far as I can ascertain, are simply reflex, and are not connected with epilepsy or with any 
organic disease. 

When he was six months old he had a number of convulsions while cutting his- 
incisors. When he was two years old he had an attack of epidemic influenza, which was 
vishered in by a convulsion ; and the same phenomenon occurred when he had an attack 
of catarrhal laryngitis some months later. 

This little girl (Case 377), four years old, is, as you see, a bright child, and is h\ fairly- 
good health. She is apparentl}^ recovering from convulsive attacks which occurred with 
great frequency in her second and third years, and which were apparently produced by epi- 
lepsy. At one time she had fifty-four convulsions in forty-eight hours. 

She has been treated simply by carefully regulating her diet and with bromide of 
potassium. 

The prognosis in this case is not very favorable, as she is probably an epileptic, and the 
convulsions are liable to return at any time, especially as puberty is approached. 

This next child (Case 378), a girl, four years old, is a case of considerable interest, as 
presenting an instance of some slight organic lesion occurring when she was two and 
one-half years old, accompanied by a convulsion. The convulsion was of the general 
clonic type, lasted for a few minutes, and was accompanied by a temperature of 39.7° C. 
(103.6° F.) and a pulse of 140. On recovering from the convulsion she was found to have 
a slight hemiplegia of the left side, which lasted for only a few hours. She then recovered 
entirely, and has since had no convulsions, but she has never developed either mentally 
or physically in accordance with what would be expected in a child of her age, so that she 
has to be watched over by her nurse as carefully as though she were three years old, as she 
is liable to fall and does not go up-stairs easily. 

This child (Case 379), three and a half years old, has always been well and strong. 
She was suddenly attacked about a month ago by a chill, and was found to have a high 
temperature and a quick pulse. A few hours later, the temperature having risen to 40° C. 
(106° F.) and the pulse to 170, she suddenly had a general clonic convulsion. After the 
convulsion had ceased she remained unconscious, and some hours later had another convul- 
sion. She was placed in a warm bath, and after the temperature had been reduced two or 
three degrees the convulsive movements ceased. A little later a general papular efilorescence 
of measles appeared on her face and neck, afterwards spreading to the body and limbs. She 



COXVULSIOXS. 761 

became perfectly conscious, and did not have any other severe symptoms during her attack 
of measles, nor any return of the convulsions. 

Her case is an instance of convulsions produced by a high temperature in the initial 
stage of one of the exanthemata. 

The next three infants whom I have had brought here to show you 
are interesting examples of the necessity of regulating the solid constituents 
of the milk which is given to young infants. 

The fii-st case (Case 380) is that of a little girl, four months old. Her mother, who was 
strong and well and apparently had plenty of good breast-milk, nursed her at birth. When 
she was three months old she began to have convulsions, which occurred almost every hour. 
Suspecting that the proportion of solids in the breast-milk was too high for the infant to 
digest them, and that they were producing a peripheral irritation which was the cause of 
the reflex convulsions, I had an analysis of the milk made, and found that the proteids 
showed a percentage of from 4 to 5. The infant was then fed with a carefully modified 
milk in which the percentage of the proteids was made 1. Within a few hours the con- 
vulsions ceased, and they have never returned. As you see, the infant is perfectly well and 
thriving to-day. 

I have in instances of this kind so regulated the percentage of proteids 
in the mother's milk by the means which I have described to jou in a pre- 
vious lecture (Lecture VII., page 188) that an infant who before this 
modification of the mother's milk had been made was having continued 
convulsions ceased entirely to have them, and was nursed successfully for 
many months. 

This next infant (Case 381), a little girl, six weeks old, began to have convulsions when 
she was four weeks old. The convulsions occurred every twenty minutes for twenty-four 
hours, and sometimes as often as every fifteen minutes. They lasted for only a few seconds. 
The infant was being fed on the milk of a Jersey cow. She was then fed on a carefully 
modified milk with a moderate percentage of fat and proteids, and the convulsions did not 
return. 

The third case (Case 382) is a boy, six weeks old. He was healthy and strong at birth, 
and was nursed by his mother for three weeks. During this time he gained in weight and 
digested the milk perfectly. The mother, however, was unable to continue nursing him 
after the third week, and it was decided to feed the infant on modified milk. The prescrip- 
tion for this modified milk sent to the laboratory by a physician was as follows : 

Prescription 72. 

Fat 5.50 

Sugar 7.00 

Proteids .... 3.50 

Soon after this milk was given to the infant it began to have convulsions, which 
continued for twenty-four hours, at intervals of two or three hours, until the milk was 
omitted. Another modification of the milk was then substituted for the first, and the infant 
ceased to have convulsions and has since digested the milk perfectly. The percentages in 
the last prescription were as follows : 

Prescription 73. 

Fat . 3.50 

Sugar 6.50 

Proteids 1.50 



762 PEDIATRICS. 

TREMOR. — Universal or partial tremor is, in my opinion, rare in 
infancy and early childhood in comparison with later life. It does, how- 
ever, occur, and is usually significant of an organic cerebral lesion. I have 
noticed it also in cases of infantile atrophy, where as recovery gradually 
took place the tremor disappeared. In thi§ form it appears to be chiefly a 
symptom of weakness. It may be quite marked as a general symptom, 
but it is not especially significant as connected either with the diagnosis 
or with the prognosis. 



THE MYOPATHIES. 763 



THE MYOPATHIES. 

Progressive Muscular Atrophy. — Pseudo-Hypertrophic Muscular Paralysis. — 
Myotonia Congenita (Thomsen's Disease). 

PROGRESSIVE MUSCULAR ATROPHY.— Progressive muscular 
atrophy is a name used to denote certain conditions which were originally 
supposed to be due to a disease of the spinal cord. Later, however, it was 
found that two forms of lesions produce this atrophic condition of the 
muscles. One of these, the neuropathic form, is an affection of the spinal 
cord, and is designated the Aran-Duchenne or thenar type. The other form 
is found to be a primary disease of the muscles, and is classed as one of the 
myopathies. 

Neuropathic Peogbessive Muscular Atrophy. — The neuropathic 
atrophies are so rare in infancy and early childhood that little need be said 
concerning them. The neuropathic progressive muscular atrophy is caused 
by a chronic degeneration of the ganglion-cells of the anterior cornua, and 
this is the form which I have just alluded to as the Aran-Duchenne t\^e. 
In this form the atrophy almost always begins in certain muscles of the 
hand, especially those of the ball of the thumb, and it is for this reason 
called thenar. It is rarely seen before the twentieth year, and is not heredi- 
tary. Hypertrophy of the muscles does not occur. 

Myopathic Progressive Muscular Atrophy. — The myopathic 
atrophies show a marked hereditary tendency. They have been divided by 
various authors according to the different portions of the body in which they 
begin. The disease in each case is essentially the same, and this division 
seems to be unnecessary and misleading, because, although the affection 
may begin in any part of the body or extremities, yet, as a rule, it may be 
said that the primary myopathies begin in the muscles of the shoulder, face, 
or back. In all these cases the atrophy usually begins before the t\^'entieth 
year. 

Where the muscles of the face and scapulo-humeral groups are involved 
early, it is called the fado-scapulo-humerar type of Landouzy and Dejerine. 

Where the atrophy begins in the gluteal muscles and those of the thigh, 
arm, and shoulder, it is called the juvenile type of Erb. 

Where the atrophy first affects the muscles of the legs, it is called the 
pefi'oneal type, and the affection shows itself in the peripheral muscles of the 
lower extremities, such as the extensors of the great toe, and afterwards in the 
common extensor of the toe and in the peroneal group. There is, h(nvever, 
regarding this latter type a doubt as to whether it is a primary myopathy. 



764 PEDIATRICS. 

Pathology. — According to Delafield and Prudden, the lesion of pro- 
gressive muscular atrophy consists essentially in a combination of simple or 
degenerative atrophy of the muscular fibres with chronic interstitial inflam- 
mation, and is sometimes associated with proliferative changes in the nuclei 
of the muscles. In the earlier stages of the disease the muscles may be 
pale and soft, but exhibit macroscopically little alteration. Gradually, 
however, the muscular substance is replaced by connective tissue, so that in 
marked and advanced cases the muscles are converted into fibrous bands or 
cords, the cicatricial contractions of which may induce great deformities. 

Microscopic examination in the early stages of the disease shows a 
proliferation of cells in the interstitial tissue, so that this may have the ap- 
pearance of granulation or embryonal tissue ; also in some cases marked 
proliferative changes occur in the nuclei of the muscles, leading to the 
formation of new cells, which may more or less replace the contractile 
substance within the sarcolemma. The new interstitial tissue increases in 
quantity and grows denser, and may crowd the muscular fibres apart. The 
walls of the blood-vessels may also become thickened. Accompanying 
these interstitial alterations the atrophy of the fibres of the muscle pro- 
ceeds. These may simply grow narrower, retaining their striations, or they 
may split up into longitudinal fibrillse or transversely into discoid masses, 
and in this condition disappear. In other cases a certain amount of fatty or 
hyaline degeneration may be present. These degenerative and proliferative 
changes do not, as a rule, occur uniformly in the affected muscles, but some 
parts are affected earlier and more markedly than others. The atrophied 
muscles may be replaced by fat. The atrophy is essentially chronic, affect- 
ing the different fibres gradually and not the whole muscle at once. 

Symptoms. — The symptoms of myopathic progressive muscular atrophy 
are those connected with a wasting of the muscles. 

In the faeio-scapulo-humeral type the atrophy of the muscles begins at 
an early age, and usually involves the face first. Both sides of the face 
are commonly affected, although the disease may be unilateral for a long 
period. The muscles chiefly affected are the orbicularis oris, the zygo- 
maticus, the orbicularis palpebrarum, the frontalis, and the buccinator. The 
levator anguli oris may also be affected, but usually is not. In connection 
with this progressive atrophy of the face the muscles of the shoulder and 
upper arm are often affected. Landouzy and Dejerine have reported an 
autopsy in a case of this facial variety in which the lesions were a primary 
degeneration of the muscles and a very slight increase of connective tissue 
and fat. In this connection I would mention that a form of what is called 
facial hemiatrophy without the involvement of any other muscles occurs 
between the fifth and twelfth years of life. 

In the "juvenile form of Erh^^ the muscles affected are usually the 
pectoralis minor and pectoralis major, the trapezius, the rhomboideus minor 
and rhomboideus major, the latissimus dorsi, the whole group of spinal ex- 
tensors, the triceps, the brachialis anticus, and the biceps. 



THE MYOPATHIE? 



'65 



In all these forms the muscles react to both the faradic and the galvanic 
current, and there is no reaction of degeneration. 

Diagnosis. — The diagnosis of myopathic progressive muscular atrophv 
should first be made from the neiu'opathic form. The former is hereditary; 
the latter is not. In the former the atrophy usually begius in the muscles 
of the shoulder, face, and back, while in the latter it is exceedingly rare for 
it to begin elsewhere than in the muscles of the hand. Hypertrophy of 
certain muscles and the beginning of the atrophy early in life, usually 
before the tenth year, are characteristic of the myopathic variety, in contra- 
distinction to the late development and the absence of hypertrophy in the 
netu-opathic form. 

The muscular atrophy which accompanies certain cases of chronic multi- 
ple netrritis may be mistaken for a myopathic affection, and must therefore 
also be differentiated. At times the resemblance of the two diseases is quite 
striking, but it does not last for a sufficiently long time to leave the diagnosis 
in much doubt. You must remember that chronic multiple neuritis is never 
hereditary, that the paralysis which accompanies it is out of proportion to 

Case 383. 




The facioscapulohumeral type of primary myopathic atrophy. I. Btjfore the disease began. 
II. After the disease was well advanced. 



the atrophy, and that there may aUo be distinct symptoms of ataxia, all of 
which symptoms are unusual in the primary myopathic atrophv. 

Progxosis and Treatment. — The prognosis is very unfavorable, and 
there is no known treatment which benefits the disease. The patient should 
be placed under the most favorable surroundings for his general health. 



766 PEDIATRICS. 

Precautions should always be taken to prevent the contractures which neces- 
sarily occur in the later stages of the disease from producing awkward 
positions of the body and limbs. 

The facio-scapulo-humeral type of primary myopathic atrophy is so 
exceedingly rare that I am fortunate in having a case here to-day to show 
you. It has been carefully attended in my wards by my colleague Dr. 

Bullard. 

Case 383. 

III. 




The facio-scapulo-humeral type of primary myopathic atrophy. Female, 10 years old. 



This little girl (Case 383), ten years old, is of healthy parentage. There are four other 
children in the family, who show no signs of disease. This child, although she has had 
various diseases, such as varicella, measles, and pertussis, has on the whole heen well and 
strong, and until three years ago was unusually well developed. Here is a picture (I., page 
765) of her taken at that time, just before she was attacked with the disease from which she 
is now suffering. 

You see that the face is unusually full and plump, and at that time there was evidently 
no sign of muscular disturbance. 

If you will now look at the child's face as she stands before you (II., page 755) and 
compare its emaciated old look with the young, well-nourished look shown in the picture 
(I.), you will at once understand that she is affected by a disease of serious import. 



THE MYOPATHIES. 



767 



Three years ago she had an attack of epidemic influenza. Since then she has been 
losing in weight and strength. She has complained of pain in the abdomen, not localized, 
but dull, continuous for a few hours, and then remitting for an hour or so. This disturb- 
ance will last for two or three days, and during this time she does not care to do anything, 
but lies down, usually on her back. She occasionally vomits ; there is nothing character- 
istic about the vomiting, but it relieves the pain of the acute attacks. She may have at 
times slight nausea ; she seldom has headache ; the bowels move regularly ; she has no 
cough, but a slight nasal catarrh is usually present, as she catches cold very easily. She 
also has enuresis, and during the acute attacks of pain she is apt to have attacks of pavor 
nocturnus. She is very nervous, and cries easily. 

Case 383. 




The facio-scapulo-humeral type of primary myopathic atrophy. 



On examining the child in front as she sits on a stool (III., page 766) you see that the 
legs are unusually well developed, in marked contrast to the atrophy of the face, body, and 
arms. Her respiration is free and equal on both sides. The face and neck are extremely 
thin, and the muscles are atrophied. The muscles of the upper extremities and chest are 
thin and small, but firm and of fair strength, while those of the abdomen and legs are well 
nourished and firm. The skin is dry, the eyes are bright, and the reaction of the pupils is 
normal. On physical examination nothing else abnormal is found, with the exception that 



768 PEDIATRICS. 

the action of the heart is rather rapid. There is slight ankle-clonus, and the patellar re- 
flexes are slightly increased. The glands of the neck, axillae, and groins are very slightly 
enlarged. The tongue is normal and can be protruded steadily. The examination of the 
urine shows it to be normal, with the exception of a slight trace of albumin. 

The only other case of this, disease which has to my knowledge been reported in this 
country is one by Osier. 

On examining the child's muscles more closely you will see (III.) that the most marked 
atrophy is situated above the diaphragm, while the abdomen and legs are remarkably well 
developed. 

The muscles affected are those which I have already enumerated in the general descrip- 
tion of the disease. 

On turning the child so as to look at her back (IV. , page 767) and making her stand 
up, you will notice the striking difference between the arms and upper part of the body 
and the legs and lower part. 

PSBUDO-HYPERTROPHIC MUSCULAR PARALYSIS. — The 

form of primary muscular atrophy which I shall next speak of is what is 
called pseudo-hypertrophic muscular paralysis. This disease is characterized 
by a diminution of power in certain muscles, accompanied by an abnormal 
increase in their size and a diminution in the size of other groups of muscles. 
Although an apparent increase in the size of the muscles takes place, yet the 
enlargement is produced by an hypertrophy of the connective tissue and an 
unusual deposit of fat. 

The disease affects males more frequently than females. It usually 
occurs between the ages of two and eight, although in exceptional instances 
its appearance is delayed until about the twentieth year. 

Pathology. — According to Gowers, the pathology is represented by a 
primary interstitial change in the muscles, showing a growth of fibrous 
tissue or of fat-cells which produces an increase in the size of the muscles. 
The muscular fibres are secondarily affected by this interstitial change, and 
are apparently narrowed by pressure. Atrophy, which is an especial feature 
of the affection, exists in the later stages of the disease in the muscles of the 
legs, and is frequently the primary pathological change in the muscles of the 
trunk and upper extremities. The development of fat-tissue between the 
atrophied fibres may prevent any diminution in the apparent size of the 
muscles. This often, in the muscles of the calves, may cause them to be 
much increased in size. In the upper extremities the deltoid and triceps are 
most commonly involved, in the lower the gastrocnemii. The infra-spinatus, 
the latissimus dorsi, and the pectoralis major muscles are also commonly 
affected. The lesion is usually symmetrical, affecting similar muscles on 
both sides of the body, but it may be unilateral. The muscles may be 
affected partially or completely. 

Symptoms. — The disease develops slowly, and the symptoms are those 
which would naturally be expected from the muscular lesions, and are quite 
eharacteristic. 

The first symptoms usually noticed are a weakness of the muscles, 
and a shuffling, unsteady, swaying gait, with the feet apart and a tendency 
to stumble and to fall. The children get tired very easily, and are noticed 



THE MYOPATHIES. 769 

to have difficulty in walking up-stairs. These general symptoms usually 
precede any noticeable enlargement of the muscles. The position on standing 
is apt to be that of lordosis, and on sitting down this curvattu-e disappears. 

The next symptom which is noticed is an enlargement of the calf- 
muscles, which are usually hard and firm. In addition to this there is an 
atrophic condition of the muscles of the shoulders and back. The muscles 
next to those of the calves which are most likely to be affected are the 
extensors of the leg, the glutei, the lumbar muscles, the deltoid, triceps, 
and infra-spinatus. The muscles of the neck, face, and upper arm are 
usually not affected, but in rare cases these muscles, as well as those of 
the tongue, have been involved. Exceptionally an hypertrophy begins in 
the upper extremities, and in these cases the deltoid muscle is usually first 
affected. At times only part of the muscle is involved. These children 
learn to walk late, and assist themselves by leaning on the furnitm-e or other 
objects in their path. Sometimes when they are kneeling on the hands and 
knees there is noticed a very characteristic saddle-shaped depression of the 
back, which is due to the weakness of the erector spinse muscles. This, 
however, is a symptom of a late stage of the disease. When the child is 
placed on the floor on its back it has difficulty in getting up. It has to turn 
over on its face first, and then to aid the weakened muscles of the legs and 
trunk by means of the hands and arms, climbing up, as it were, upon itself 
by placing the hands upon the knees and then farther and farther up the 
thighs. Fibrillary contractions do not occur. The knee-jerks in some cases 
disappear as the disease advances. Sensation, as a rule, is normal. There 
is seldom any disturbance of the bladder or rectum. 

As the disease advances, the pseudo-hypertrophic condition disappears 
and is succeeded by atrophy. In some cases the atrophy occurs without the 
preceding hypertrophy. In the later stages of the disease contractions of 
the muscles occur, and in this way permanent distortions of the joints may 
result. The most common deformities are talipes equinus and flexion of 
the knees and hips. There may be such a contraction of the biceps as to 
prevent full extension of the arm, and in some cases the contraction of the 
muscles of the calves is so great as to prevent the child from placing the 
heels upon the ground. 

According to Bradford and Lovett, lateral curvature of the spine may 
occur, and at other times a permanent flexion of the spine from weakness 
of the erector spinae muscles, so that the child sits bowed forward. The 
electrical reactions are not altered to any degree until the muscles have 
reached a marked stage of atrophy, then they are diminished in proportion 
to the muscular wasting, and finally they are lost. The reaction of degen- 
eration is never present. 

Diagnosis. — The diagnosis of pseudo-hypertrophic muscular pamlysis 
when the disease is well established is not difficult. The peculiar gait, the 
size of the calf-muscles, entirely out of proportion to their strength, and tlie 
characteristic manner in which the child rises from the floor, at once sug- 

49 



770 



PEDIATRICS. 



gest this affection. Gowers also attaches diagnostic importance to the co- 
existence of enlargement of the infra- spinatus and wasting of the latissimus 
dorsi and the lower part of the pectoralis major muscles. We should re- 
member that in pseudo-hypertrophic muscular paralysis, in contradistinction 
to progressive muscular atrophy, the small muscles of the hand and of the 
face are, as a rule, not affected, that pain is usually not present, and that 
changes in the nutrition of the skin and nails do not occur. 




Pseudo-hypertrophic muscular paralysis, showing enlarged calves. 



We differentiate true muscular hypertrophy from pseudo-hypertrophic 
paralysis by the strength which accompanies the former, and by the weak- 
ness which occurs in the latter. 

In the early stages of the disease it is at times difficult to distinguish 
simple backwardness in walking from early pseudo-hypertrophy, but the 
characteristic symptoms of pseudo-hypertrophy, which develop very soon, 
do not leave the diagnosis long in doubt. The same thing may be said of 
differentiating pseudo-hypertrophy from the muscular disturbances occur- 
ring in idiocy, spastic paralysis, rhachitis, and Pott's disease. 



THE MYOPATHIES. 



771 



Prognosis. — Recovery in this disease is unknown, and the children 
•seldom live to middle life. Death usually occurs from some intercurrent 
disease. The course of the disease is chronic. The muscular weakness, the 
lordosis, and the peculiar gait last for several months or a year. The hyper- 
trophy of the muscles then begins, and continues progressively for one or 
two years, when it reaches its maximum and becomes stationary, remaining 
so for several years or even longer. A stage of increasing feebleness and 
extension of the paralysis then begins, the muscles become more wasted, and 
the power of motion is lost in the legs and arms. Sometimes the disease 
after remaining stationary ra})idly advances to a fatal issue. 

Treatment. — At present we know of no way of curing the disease. 
Massage has proved to be more beneficial than the use of electricity in these 
eases. Systematic muscular exercise, for the purpose of preserving the 
nutrition of the unaffected muscular fibres and to ward off the permanent 
eontractures, is indicated. Where the muscles are drawn up, tenotomy is 
often of much use, and division of the tendo Achillis on both sides may 
for a long time restore the power of w^alking. Bradford and Lovett 
advise tenotomy of the hamstring tendons also, in severe cases. Strict 
attention to the health and hygiene of the patients, combined with muscular 
exercise and tenotomy, will often improve the general condition for a con- 
isiderable period of time. 

Case 384. 




fc 



Pseudo-hypertrophic muscular paralysis. Showing position at^sumed in rising from the floor. 



I have here a case which represents certain })oints ^vhich I have just 
spoken of in describing pseudo-hypertrophic muscnlar paralysis, and which 
I am enabled to SJiow you tlirough the kindness of Dr. Rupert Norton. 



772 



PEDIATRICS. 



Looking at this boy from behind (Case 384, I., page 770), you will notice at once that 
the calves of the legs are greatly enlarged. 

On making the boy lie down on the floor and then telling him to get up (II. , page 771), 
you will notice that he assists himself by putting his hands on his knees and gradually 
higher and higher on the thighs until he assumes the erect position. 

I shall now ask you to look at these illustrations of two brothers which 
I am enabled to show you through the kindness of Dr. H. N. Thomas, of 
Baltimore. 

The history of these cases (Cases 385 and 386) is as follows. The smaller boy is eight 
years old, the larger ten years old. They have always lived in the country, and no mention 
of any especial disease has been obtained, but the history of both cases is unsatisfactory. 

Cases 385 and 386. 




Pseudo-hypertrophic musciilar paralysis. Brothers, 8 and 10 years old. I. Showing atrophy of back and 
enlarged calves. II. Showing the lordosis. 



The older boy began to walk when he was nineteen months old, but was clumsy and 
never walked well. When he was seven years old he began to have difficulty in going up- 
stairs, and it was noticed that the calves of his legs were growing larger, while his arms 
were becoming smaller. The curve in his back was first noticed when he was eight years 
old. "When nine years old he lost the power of walking, and is said to have grown rather 
stupid. 



THE MYOPATHIES. 773 

The younger boy was always delicate, but never had any disease, and began to walk 
when he was fifteen months old. He learned to walk pVetty well, but when he was four 
years old he began to show weakness in the legs and ankles, and this weakness increased 
steadily. AYhen he was six years old his arms began to get smaller and his legs to increase 
in size. 

You see that both boys show marked lordosis. 

MYOTONIA CONGENITA (Thomsen's Disease).— A third form of 
primary mjopatliy, which is usually termed Thomsen's disease, from the 
name of the physician who first thoroughly described it, is characterized by 
an inhibition of the voluntary movements. This disturbance of movement 
is due to a stiffness and tension of the muscles occurring at the commence- 
ment of motion. The most important etiological factor in the disease is 
that it is hereditary. In almost every case it begins in early childhood. 

The pathology of the disease has not been accurately established by 
means of autopsies, but an examination of sections of muscle taken from 
these cases has shown, according to Erb and Jacoby, that the morbid 
changes are the result of an enormous hypertrophy of all the muscular 
fibres, great proliferation of the nuclei, and a slight increase of the peri- 
mysium. The disease appears to be a congenital affection of the muscular 
fibres. 

The symptoms of this disease are noticed only during voluntary move- 
ments, the contraction of the muscles responding very slowly to the will, 
and persisting for a little time after the individual has willed the muscular 
movement to cease. The muscles of the arms and legs are those usually 
implicated. The sensation and reflexes are normal. The muscles are 
apparently enlarged, giving at times the appearance of hypertrophy, but the 
strength of the muscle is not proportionate to its size. Erb has described a 
characteristic electrical reaction, called the myotonic reaction, in which the 
contractions caused by either current attain their maximum slowly and 
relax slowly, and wave-like contractions pass from the cathode to the 
anode. One of the peculiarities of the disease is that when exertion is 
made, such as attempting to go up-stairs, the muscles which previously 
were quiescent become very stiff and will scarcely respond to the will. 
Another peculiarity is that long-continued rest makes the disorder worse. 
It is also exaggerated by heat, cold, and excitement. 

Since the discovery of the myotonic reaction the diagnosis of the disease 
is not difficult. 

Although at times it may recover temporarily, the disease is incurable, 
and there is no known treatment which is of benefit to it. 



DIVISION XIL 

DISEASES OF THE MOUTH, NOSE, NASOPHARYNX, 
AND PHARYNX. DIPHTHERIA. 



LKCTURE XL, 



DISEASES OF THE MOUTH. 



Stomatitis Catarrhalis. — Stomatitis Herpetica. — Stomatitis Ulcerosa. — Sto- 
matitis Mycetogenetica. — Glossitis. — Microglossia. — Macroglossia. — Dif- 
ficult Dentition. 

In speaking of diseases of the mouth you must understand that much 
confusion exists as to the nomenclature of this class of affections. Thus, a 
great variety of names has been used by different authors to describe the 
same disease, so that at times it is quite difficult for one investigator to 
compare his work with that of another. Such terms as " canker" and 
" aphthae" are so commonly used for almost any morbid condition of the 
mucous membrane of the mouth that they have ceased to convey any 
definite idea. 

It has therefore been found necessary, in order that any advance should 
be made in this most difficult department of medicine, to adopt some more 
exact nomenclature, so that physicians in different parts of the world should 
in every case use the same name for the same disease. In furtherance 
of this object the American Pediatric Society has adopted a provisional 
nomenclature of the diseases of the mouth which was prepared by Dr. 
Forchheimer, of Cincinnati, and myself. To Dr. Forchheimer's extended 
investigations on this subject I am much indebted. 

Diseases of the mouth occur more frequently and in much greater 
variety in infancy and in early childhood than at any later jieriod of life. 
This depends partly on the anatomical conditions at different periods of 
development and partly on the external influences which are brought to 
bear upon the buccal mucous membrane. During the first three or four 
months of life the function of the salivary glands is not developed, and the 
flow of saliva is insignificant. This lack of saliva allows the mucous 

• 774 



DISEASES OF THE MOUTH. 775 

membrane of the mouth to be dry in comparison with that of the older 
subject. Even after the saliva is secreted the infant is more apt under 
certain conditions to let it flow from the mouth than to swallow it, so 
that the mucous membrane of the lips and mouth may present a different 
appearance in young infants, when they are attacked by various morbid 
processes, from that seen at a later period of development. We must also 
remember that the salivary glands in addition to their especial function are 
excretory organs, and that substances which are absorbed by the stomach 
may be eliminated by the mouth and in this way become sources of irri- 
tation and disease in the latter. The mucous membrane of the mouth 
during almost the whole period of infancy is subject to external sources of 
irritation to which older children, as a rule, are not liable. Thus, during 
the first year the mucous membrane is subjected to more or less mechanical 
irritation through the mechanism of sucking. At this period, also, it is 
very common for foreign organisms to be introduced into the mouth by 
means of the fingers either of the infant itself or of its attendant. It is 
not surprising, therefore, that we should meet with a great variety of patho- 
logical conditions in the mouth in infancy. 

The organisms which occur in the mouth are so numerous that very 
few of them have as yet been differentiated in such a way that they can be 
known as the cause of the specific disease in which they are often found. 
We cannot, therefore, at the present time describe the various diseases 
of the mouth under their proper etiological headings, and we are forced 
to adopt provisionally the name of the pathological lesion which exists in 
them. 

In almost every disease of the mouth which occurs in infants and in 
young children you will find a coexisting inflammation of the mucous 
membrane of the mouth. This inflammation may at times be very mild 
and often diflicult to detect as such, but it still presents a recognizable 
pathological condition. This inflammatory condition, though not neces- 
sarily preceding the various diseases, yet in a large number of cases either 
exists as a basis on which the disease develops, or so closely accompanies it 
that the general name stomatitis (inflammation of the mucous membrane of 
the mouth) seems to be a proper term to use in connection with all these 



Under the general heading stomatitis we can speak of most of the 
important diseases which affect the mucous membrane of the mouth in 
infancy and early childhood. These diseases may be divided into four 
general headings, according to the character of the lesions which occur in 
them. In order that you may readily understand the classification of each 
disease when I speak of it, I shall first show you a table (Table 107) of the 
provisional nomenclature which has been adopted by the American Pediatric 
Society. 



776 



PEDIATRICS. 



TABLE 107. 

Provisional Nomenclature of Diseases of the Mouth. 
Simplex. 



Stomatitis 



' Catarrhalis 



Exanthematica 



Traumatica 



Herpetica Aphthosa, 

f Scorbutus 
Ulcerosa 



Mineral Poisons . 
And other diseases. 
f Hyphomycetica . 



■{ 



Secondary to the 
Exanthemata. 
Mechanical. 
Thermal. 
Chemical. 



Arsenic. 

Lead. 

Mercury. 



Mycetogenetica 



- Pseudo-Membranosa 



Thrush. 
r Diphtheria. 
! Tuberculosis. 



I 

I Gangrenosa Nomj 



Syphilis, 

and like diseases. 



Following this table, you will see that the four general names which cover 
all these diseases are stomatitis catarrhalis^ stomatitis herpetica, stomatitis 
ulce7'osa, and stomatitis mycetogenetica. 

STOMATITIS CATARRHALIS.— The form of stomatitis which is 
called the simple or erythematous form (stomatitis simplex) is commonly seen 
in young infants as a hypersemic condition of the blood-vessels, causing 
diffuse redness of the whole buccal mucous membrane. This erythematous 
form is so common and so entirely without clinical significance that it may 
be considered as physiological and need only be referred to. 

The second form, which is called exanthematica, is the condition of the 
mucous membrane which occurs secondarily to the exanthemata. This con- 
dition of the mucous membrane has already been described in connection 
with these diseases, and therefore need not be spoken of again. 

The third form, which is called traumatica, is the one which represents 
the characteristic stomatitis catarrhalis. The causes of the traumatic form 
of stomatitis catarrhalis are very numerous. They may be mechanical, 
thermal, or chemical. Among the most common mechanical causes may be 
cited the irritation produced by rubber nipples, too vigorous cleansing of the 
mouth, injudicious rubbing of the gums during dentition, and local irrita- 
tion from a tooth. The thermal form of traumatism may result from the 
administration of food which is too hot. The chemical irritation may arise 
in various ways, as from lack of cleanliness in the mouth, with its result- 
ing fermentation, and from the elimination of irritating products from the 
glands apparently connected in some way with disturbance in the gastro- 
enteric tract. It is probable also that various forms of bacteria or their 



DISEASES OF THE MOUTH. 777 

products mav cause both mechanical and chemical irritation of the buccal 
mucous membrane. Our knowledge of the bacteriology of the mouth is as 
yet, however, so limited that we can scarcely undertake to describe the 
relation between special forms of bacteria and special lesions of the mucous 
membrane. 

Pathology and Symptomatology. — As the lesions which are seen 
in the mouth of an mfant with stomatitis catarrhalis during life almost 
entirely disappear at death, and as very few post-mortem examinations have 
been made of these lesions, we can speak of the pathology and svmptoms of 
this disease together. 

The lesion is essentially an inflammatory one, and occurs in different 
grades. On examining the mucous membrane in these cases it is seen that the 
entire lining of the mouth is intensely reddened, that the temperature of the 
mouth is increased, that there is usually a certain amount of swelling, and 
that, although the mucous membrane may be under certain circumstances, 
especially at first, dry, yet, as a rule, later there is a hypersecretion of 
mucus and saliva. The blood-vessels are so distended and their walls are 
apparently so weak that the slightest traumatism may cause their rupture, 
and the saliva is frequently mixed with a little blood. In older children 
the mucous membrane may be considerably swollen, especially behind the 
incisor teeth. In addition to this general condition of the mucous mem- 
brane of the mouth, at times the lips are found to be swollen and much 
reddened. The surface of the mucous membrane shows a number of small 
roimd prominences, which are the muciparous follicles. If complete occlu- 
sion of the ducts of these follicles occurs, great dilatation of the gland will 
take place, and a cyst may be formed. This, however, is a comparatively 
rare complication. In connection with the disturbance of the glands in the 
mouth the lymphatic glands are usually involved secondarily. 

When the catarrhal condition is at its height the mucous membrane is so 
vulnerable that even slight traumatisms may cause abrasions. The most 
marked symptom of stomatitis is pain. The infant is restless, usually has 
a heightened temperature, and refuses to take its nomishment. The saliva 
is acid in its reaction, and when secreted in large quantities flows out of the 
mouth upon the chin and neck, sometimes causing considerable irritation. 
The tono^ue is drv and white at first, then becomes of a o-ravish color, and 
as the secretion of saliva increases the coating of the tongue is washed off 
and its surface becomes red. 

Prognosis. — The prognosis of stomatitis catarrhalis is, as a rule, good. 
Although the disease does not run a definite course, yet in most cases after a 
few days the pathological condition improves and the symptoms grow less 
severe. The course of the disease is, howcA-ier, otlen lengthened by the 
secondary conditions which arise from the gastric disturbances, which may 
be caused by swallowing the irritating secretions of the mouth. In weak, 
poorly noiu-ished infants who refuse to nurse or to take the food whicli is 
o'iven them, serious results mav arise from a lack of sufficient nourishment, 



778 PEDIATRICS. 

SO that in these cases the prognosis is always grave. In older children the 
disease may be considered to be of a benign nature. 

Treatment. — Although stomatitis catarrhalis may run a favorable 
course without any treatment whatever^ yet there are so many causes which 
may prolong its course or give rise to secondary affections that it is exceed- 
ingly important to treat the disease at once. The indications for treatment 
are to relieve the pain and to allay the irritation of the mucous membrane 
so that a sufficient amount of nourishment may be taken by the infant to 
prevent it from being harmed by a lack of nourishment or by a secondary 
disturbance of the gastro- enteric tract. If the cause can be ascertained, it 
should be removed at once. The local application of a one to two per cent, 
cold solution of bicarbonate or borate of sodium in distilled water is indi- 
cated. This solution should be used very gently every half-hour when the 
infant is a>vake, by means of a dropper, and occasionally on a clean swab of 
absorbent cotton. The infant should be systematically fed at regular inter- 
vals, whether it resists or not ; and if it is not being nursed or will not suck 
from the nipple, a carefully modified milk at a temperature of about 32.2° 
C. (90° F.) should be administered with a spoon or dropper. There is no 
necessity for giving any drug internally in this disease. 

Where the stomatitis proves to be intractable and lasts for more than 
three or four days, the mouth can be gently touched with a cotton swab wet 
with a one per cent, solution of nitrate of silver. This should be done 
once a day, and the mouth washed carefully with cold sterilized water after 
the application. 

Where there are any abrasions which show a tendency to extend or to 
form an ulcer, they should be touched with a little nitrate of silver melted 
on the end of a silver probe. These abrasions are often so painful that in 
themselves they may prevent the child from taking its food, and after they 
have been treated with the nitrate of silver the child will often again take 
its nourishment readily. 

I have here an infant (Case 387), six months old, who is a marked case of stomatitis 
catarrhalis. This infant is reported to have always been healthy, and is being nursed by 
its mother. It cut its first tooth, a middle lower incisor, when it was five months old. 
Nothing abnormal was noticed about the infant until two weeks ago, when it became fret- 
ful, restless, had a heightened temperature of about 38.8° C. (102° F.), and vomited occa- 
sionally. Although it did not cry a great deal, it frequently whimpered, as though in pain, 
and kept putting its fingers to its mouth. A few days later it refused to nurse. When it 
was put to the breast it appeared to be hungry and would take hold of the nipple vigor- 
ously, but immediately afterwards would draw its head awa}^, as though sucking the nipple 
caused pain. 

A physical examination shows nothing abnormal about the infant except in its mouth. 
The mucous membrane of the mouth, tongue, and gums is reddened, and small raised spots 
are seen corresponding to the positions of the muciparous glands. The mucous membrane 
of the tongue and lips is somewhat swollen and hot, and evidently sensitive to the touch. 
Where the tooth touches the tongue the inflammatory condition is especially marked, and 
it is possible that the sharp edge of the tooth was the original starting-point of the general 
inflammation which is now present. 

In this case the indications are for active treatment, as the infant is losing in weight 



DISEASES OF THE MOUTH. 779 

from lack of sufficient nourishment, and if this continues the prognosis will soon become 
grave. When the mouth is in this condition there is also a great liability to other diseases 
being implanted upon it, as the mucous membrane is very vulnerable when a pronounced 
stomatiiis catarrhalis is present. The saliva is flowing from the mouth in such quantities 
and is so irritating that an eczematous condition has been produced by it on the chin. 
The child is rather apathetic and does not like to be disturbed. The treatment which I 
shall order in this case is that the mouth be carefully washed with the following solution 
(Prescription '-i) : 

Prescriptiox 7-i. 

Metric. Apothecary. 
Gramma. 

R Sodii bcratis 18 R Sodii boratis gr. xxx ; 

Glycerini 7 j 5 Glycerini . . ^ii ; 

Aq. destil ad 120 | 00 Aq. destil ad ^iv. 

M. M. 

This should be applied every hour while the child is awake. The chin should be 
frequently dried gently and a little vaseline applied to the eczematous surface. Until the 
child is willing to nurse again, the milk should be given by means of a dropper regularly 
every two hours. Under this treatment I shall expect rapid improvement within four or 
five days. 

STOMATITIS HERPETICA.—The name herpetica has been adopted 
for the next form of stomatitis, because it seems to represent most nearly 
the lesion which is seen on the mucous membrane, although it is not de- 
finitively settled that it is a true herpes. 

The disease consists of a catarrhal stomatitis in the course of which 
certain lesions resembling subepithelial vesicles surrounded by areolae occur 
irregularly and in dilFerent parts of the entire buccal cavity. This form of 
stomatitis has usually been known as stomatitis aphthosa {a<pOa^ an eruption 
or ulceration.) This name was given to it by Bohn as distinctive from the 
other forms of stomatitis, but it does not represent the affection especially 
well. 

Etiology. — As a rule, when the mucous membrane of the infant's 
mouth is in a normal condition it is not readily affected by the various irri- 
tants which produce its special diseases. When a catarrhal condition is 
present the mucous membrane becomes more vulnerable and the various 
diseases have an opportunity to develop. This apparently is illustrated in 
the case of stomatitis herpetica, in conjunction with which affection a 
catarrhal stomatitis is always found. Xo cause, either local or general, has 
as yet been determined for this disease. Various micro-organisms have 
been observed in the mouth when it is affected by stomatitis herpetica, but 
no causal connection has been discovered between them and the disease. 
This affection may be found associated with a number of other diseases, but 
usuallv occurs alone. It does not seem to be contagious, nor to be especially 
connected with diseases of the gastro-enteric tract or with dentition, although 
it very commonly occurs during the dental period. It appeal^ to be the 
result of certain deleterious influences which act upon the nerve-centres and 
produce an herpetic efflorescence on the mucous membrane which corresponds 
closely to that which is seen in herpes on the skin. 



780 PEDIATRICS. 

Pathology and Symptomatology. — In addition to the usual lesions 
of a stomatitis catarrhalis, spots^ not necessarily symmetrical or unilateral, 
of different sizes and of different shades of white or grayish- white^ appear 
in various parts of the mouth, especially on the inner surface of the lip, on 
the side and under surface of the tongue, and on the gums. These lesions 
do not affect the follicles of the mouth, and the efflorescence cannot be called 
follicular, as it is closely connected with the muciparous glands. The lesions 
make their appearance with great rapidity, and develop very quickly from 
a macule into what is supposed to be a vesicle. The action of the secretions 
of the mouth upon these lesions necessarily prevents them from having the 
same definite appearance that they would present on the skin. The course 
of the disease so strongly simulates that of herpes that at present it would 
seem wise to consider the efflorescence herpetic. 

The general appearance of the efflorescence when at its height is that 
of a subepithelial vesicle, somewhat glistening, of a whitish-gray color, and 
surrounded by a red areola. The lesions may be only a few in number, 
scattered irregularly over the parts of the mucous membrane which I have 
already described. At times, however, the efflorescence is very diffuse, some- 
times appearing as minute grayish points, which may become much larger 
and cover the mucous membrane so thickly as almost to simulate a false 
membrane. In a still later stage of the disease these lesions may break 
down and form small superficial ulcers. 

An infant or young child affected by stomatitis herpetica presents a very 
characteristic appearance. It looks dull and apathetic, and wishes to lie 
quietly in bed. It usually has a heightened temperature, and evidently 
suffers from pain and heat in its mouth. The saliva flows from the mouth 
in large quantities, and often irritates the chin and neck to such an extent 
that an eczematous condition results. The child refuses to take its nourish- 
ment, and is very fretful and restless. These symptoms continue for four 
or five days or a week, and sometimes extend over a period of two weeks, 
the disease then disappearing of itself: in fact, it appears to be self-limited. 
Unless the lesions of stomatitis herpetica are complicated by those of stoma- 
titis ulcerosa, the saliva is never fetid. 

Prognosis. — The prognosis of stomatitis herpetica is very favorable, 
although infection from other diseases may take place. This latter occur- 
rence isj however, exceedingly rare. Relapses are very uncommon in this 
form of stomatitis, and the lesions usually heal readily. 

Treatment. — There is no internal treatment which is of benefit in this 
disease. The indications for treatment are to allay the irritation of the 
mucous membrane and to prevent its infection by some other poison. The 
mouth in general should be treated as I have just recommended in the case 
of stomatitis catarrhalis. As a rule, very little treatment is necessary 
beyond occasionally cleansing the mouth with the solution (Prescription 74, 
page 779) already mentioned. The ulcers which do not heal readily can 
be touched with nitrate of silver. After the first few days, and earlier if 



.ATE Vli 









Follicular Tons 



DISEASES OF THE MOUTH. 781 

the disease has attacked a puny, ill-nourished infant, great care and perse- 
verance should be exercised to feed at regular intervals. 

This boy (Case 388, Plate VIII., Stomatitis Herpetica), four years old, whom you 
see here in a darkened corner of the ward, is a pronounced case of stomatitis herpetica. 
He was perfectly well until two days ago, when he began to be feverish, was restless at 
night, refused to take his food, and seemed quite sick. On the following day the entire 
mucous membrane of the mouth was found to be aifected with stomatitis catarrhalis, and 
somew^hat later the herpetic form of stomatitis, which you now see in different parts of the 
mouth, appeared. 

On drawing down the lower lip you see on the right side a number of small grayish- 
white spots surrounded by a somewhat deeper, reddened mucous membrane. At a little 
distance from them, on the left side of the lip, close to the gum, is apparently a subepithelial 
vesicle. On the inner side of the lower gum one of these vesicles has broken down, and a 
small superficial ulcer covered with a grayish- white exudation is seen. There are also 
lesions of the same vesicular character along the left edge of the tongue. The entire 
mucous membrane of the mouth is intensely reddened, and the case illustrates stomatitis 
catarrhalis as well as stomatitis herpetica. 

The child absolutely refuses to take food, and, as he is robust, I have not advised 
that a great deal should be forced upon him. In a few days the more severe stage of the 
disease will have passed away and he will take his food. In the mean time the inflamed 
mucous membrane can be bathed with cold sterilized water, and small quantities of an 
alkaline modified milk can be given to him. As you look at this child lying with his eyes 
half closed, with fiushed cheeks, in an apathetic condition, occasionally whimpering as if 
in pain, and with the saliva flowing continuously from his mouth on the pillow, you can 
readily diagnosticate the disease stomatitis. "When in addition you see these characteristic 
lesions of the mucous membrane irregularly distributed throughout the buccal cavity, and 
do not find any evidence of a membranous exudation, there need be no doubt of the 
diagnosis. Internal remedies are not needed in a case of this kind. Chlorate of potas- 
sium, which is so commonly used in all diseases of the mouth, is not indicated in the forms 
of stomatitis of which I have just spoken. 

In connection with this form of stomatitis may be mentioned certain 
lesions occurring in the mouths of new-born infants which have been called 
Bednar^s aphthw. These lesions consist of small superficial ulcers usually 
having a grayish coating, and appearing on the posterior part of the hard 
palate and on the soft palate. They are now supposed not to represent a 
specific disease, but to be the result of traumatism, such as may arise from a 
badly-shaped rubber nipple or from undue violence in washing the mouth. 

They are to be treated as any local irritations of the mouth should be, 
— namely, by removing the cause, applying a solution of bicarbonate of 
sodium, and, if necessary, touching them with nitrate of silver. 

STOMATITIS ULCEROSA. — By stomatitis ulcerosa we mean a pecu- 
liar pathological process of the mucous membrane of the mouth occurring 
only where there are teeth and affecting the gums around the teeth. 

Etiology. — This affection of the mouth may occur in the course of a 
number of diseases, notably in scorbutus. It may also be produced by the 
internal administration of such mineral poisons as arsenic, lead, or mercury. 
Occasionally it may occur as a local affection without known cause, but it is 
probably produced by the irritation of some form of micro-organism not 
yet determined, although the pyogenic bacteria are very coninionly jiresent. 



782 PEDIATRICS. 

The most common form of stomatitis ulcerosa produced by the mineral 
poisons is that which is seen in connection with mercurial salivation. 

As in the other forms of stomatitis, it is probable that the mucous mem- 
brane is first affected by a catarrhal process which renders it vulnerable to 
the special irritation which produces stomatitis ulcerosa. This preceding 
stomatitis catarrhalis may be produced directly by local irritation in the 
mouth itself, or may be the result of some disturbance of the general 
system. For this reason stomatitis ulcerosa, as a rule, does not affect 
primarily a healthy individual. Thus, a poorly nourished child, and one 
whose mouth is not properly cared for, will be more apt to have this disease 
develop than one who is correctly fed and whose mouth is clean. 

Pathology. — The pathological condition is one of necrobiosis ; that is, 
there is softening as well as death of the tissues. The disease, although 
starting in the mucous membrane, may extend to the periosteum, and even 
produce necrosis of the bone. It begins at the free border of the gums, 
and can extend in all directions, but it never passes beyond the mucous 
membrane of the mouth. The softening of the tissue not only changes 
its consistency but also renders it more movable, and in this way the gums 
at times become so swollen and loosened that they may entirely cover the 
teeth. 

Symptoms. — Stomatitis ulcerosa is usually preceded by moderate consti- 
tutional symptoms, such as fever, loss of appetite, and fretfulness. The 
mucous membrane of the gums at the free margin of the teeth becomes 
reddened and soon begins to swell. The normal curve of the gum becomes 
almost a straight line and covers the lower part of the teeth. The gums in 
the spaces between the teeth remain unaltered at first. The mucous mem- 
brane then begins to change in color and becomes purplish. Extreme con- 
gestion and softening of the tissues allow hemorrhage to take place from 
the slightest pressure. Although the anterior surface of the gums is most 
commonly affected, yet in severe cases the posterior surface is also involved. 
As the process develops further the gum becomes more and more loosened 
as it extends over the teeth. A muco-purulent secretion collects between 
the gum and the teeth and causes a fetid odor. According to Forchheimer, 
a yellowish seam then appears at the top of the swollen outline of the gum. 
This is due to the molecular destruction which has already begun. This 
seam is at first very narrow, but later it may become broader and involve 
almost the whole of the gum. In connection with this characteristic ap- 
pearance of the gums there is a great hypersecretion of saliva. At the 
height of the disease the child evidently suffers from pain in the mouth, 
cries a great deal, and rapidly emaciates. The lymphatic glands are usually 
swollen, and remain so until the disease has ended. When the yellowish 
material which constitutes the seam already referred to is removed, an ulcer- 
ated surface will be found beneath. Although stomatitis ulcerosa may begin 
about any of the teeth, its most common starting-point is around the lower 
incisors. As the disease improves, the gums gradually become less swollen 



DISEASES OF THE MOUTH. 783 

and congested, returning to their normal relation to the roots of the teeth, 
and the salivation disappears. 

Diagnosis. — The differential diagnosis of stomatitis ulcerosa ^yhen the 
lesions of the disease are marked presents no difficulty. Although an 
herpetic efflorescence may occur coincidently with the ulcerative form, yet 
the pictures of the two diseases are so different that you will at once know 
that you are dealing with two affections rather than with one. There is no 
other disease of the mouth in which the gums assume the purplish hue 
and the swollen, soft, and loosened condition which are characteristic of 
stomatitis ulcerosa. 

Prognosis. — The prognosis of stomatitis ulcerosa depends upon its 
cause and whether it is treated or not. The tendency is, however, after a 
variable period of discomfort to the child, for the disease to disappear. 

If the affection is the result of one of the constitutional diseases, such as 
syphilis or scorbutus, it disappears if the treatment of the specific disease is 
beneficial, otherwise it continues, and may finally lead to death by exhaustion. 

Treatment. — The local form of the disease is best treated by the 
internal administration of chlorate of potassium or by this drug in solution 
used as a wash for the mouth. Chlorate of potassium must, however, be 
given with great precaution to infants and children, as in certain cases it 
acts as a poison, some infants being affected by even minute doses. The 
symptoms which show that chlorate of potassium is producing deleterious 
effects in infants who are most likely to be affected by the drug are drowsi- 
ness and suppression of urine, with weakness of the heart and sometimes 
cyanosis. When these symptoms follow the administration of the drug it 
should be omitted at once and a simple wash of borate of sodium used. 
Chlorate of potassium when given internally has been found to be secreted 
in the saliva within five or ten minutes, and thus has an opportunity of 
producing a direct effect upon the lesions of the gums. The doses of chlo- 
rate of potassium which it has been found can be safely administered to 
infants and children should be remembered when prescribing the drug. I 
have indicated in this table (Table 108) the minimum doses which can safely 
be given in the twenty-four hours at different ages, and which are sufficient 
to produce the specific effect of the drug in treating cases of stomatitis 

ulcerosa. 

TABLE 108. 

Amount of Chlorate of Potassium lohich can be safely given in Tioenty-Four Hours at 

Different Ages. 
Asre Gramme. 



Under 1 year 1 

1 to 2 years 1 

2 to 6 years 2 

6 to 8 years 2 

8 to 14 years 3 



In order that the chlorate of potassium shall produce the best effects it 
should be given frequently. The total amount for twenty-four hours which 



784 PEDIATRICS. 

is to be given at any special age is to be placed in a tumbler and dissolved 
in as many tablespoonfuls of sterilized water as there are doses to be given 
within the twenty-four hours. I usually tell the nurse to calculate about 
how many hours the child will sleep out of the twenty-four. Supposing 
the number of hours is ten : I then tell her to prepare fourteen tablespoon- 
fuls of the solution and to give the child one tablespoonful every hour that 
it is aAvake. The administration of chlorate of potassium at first usually 
produces considerable smarting and pain in the mouth as it passes over 
the inflamed surface of the mucous membrane. These symptoms, however, 
last for only a short time, usually disappearing entirely after from thirty- 
six to forty-eight hours. 

Under this treatment the disease is ordinarily cured in a week or ten 
days. The treatment should, however, be continued for a number of days 
after the mouth is apparently entirely well. 

Where deeper ulceration has taken place, its disappearance may some- 
times be expedited by the application of nitrate of silver. Where a seques- 
trum has formed, it must be removed. Frequent washing of the mouth with 
sterilized water administered by means of a dropper is also very important, 
especially after the taking of food. 

I have here an infant (Case 389, Plate VIII., facing page 781, Stomatitis Ulcerosa 
in Scorbutus), ten months old, in whose mouth you will see the characteristic lesions of 
stomatitis ulcerosa. In this case the disease happens to be secondary to scorbutus, the affec- 
tion for which the infant is being treated. 

You will notice that the infant has six teeth, and that the mucous membrane is affected 
only at the junction of the gums with the free surface of the teeth. The other parts of 
the mucous membrane of the mouth are reddened, but not markedly so. The portions of 
the gums affected are swollen, purplish, loosened, and almost cover the teeth. There is a 
considerable flow of saliva, with a fetid odor from the mouth. An appearance of this kind 
is diagnostic of stomatitis ulcerosa. 

I also have here a case of stomatitis ulcerosa which apparently is of local origin. This 
little girl (Case 390) is three and a half years old. She has always been healthy, and has 
had no diseases of any kind. She was perfectly well until five days ago, when she began to 
have loss of appetite, a temperature varying from 38.3° to 39.4° C. (101° to 103° F.), and to 
be very fretful. Three days later the gums were noticed to be swollen and to be of a dark 
red color, and her breath had a fetid odor. During the past two days 1.5 grammes (25 
grains) of chlorate of potassium have been given to her in divided doses in the twenty- 
four hours, and, although she has been rather apathetic and has wished to remain in bed, her 
mouth to-day is in a much healthier condition, and she is brighter and has a little return of 
appetite. 

In two or three days more the disease will probably have run its course and entire 
recovery will have taken place. The salivation, which was very marked in the early days 
of the disease, is now quite moderate. 

During the first three days her restlessness was so excessive at night that 0.3 gramme 
(5 grains) of bromide of potassium had to be given to her to produce sleep. 

STOMATITIS MYCETOGENBTICA.— There are three forms of 
vegetable parasites which occur in or upon the human body : (1) bacteria, or 
fission-fungi (schizomycetes) ; (2) yeasts, or yeast-fungi (saccharomycetes) ; 
(3) moulds, or mould-fungi (hyphomycetes). The changes in the tissues 



DISEASES OF THE MOUTH. 785 

whicli are due to fungi are termed mycetogenetic metamorphosis, and thus 
the pathological conditions in the mouth which are produced by any of 
these forms of fungi may be designated by the general term mycetogenetica. 
Under this general heading of mycetogenetica we can include the various 
forms of stomatitis which are caused by fungi. 

Stomatitis Hyphomycetica (Thrush), — The disease which is com- 
monly called thrush is produced by a fungus which finds its nidus upon the 
surface of the mucous membrane of the mouth, usually in young infants. 
This fungus was formerly supposed to be the o'idium albicans, but it is 
now known not to be this organism, and the precise form of mould which it 
represents has not yet been determined. We merely know that this growth 
of thrush is one of the mould-fungi, and we can therefore at present only 
classify it as stomatitis hyphomycetica. 

The moulds are complex in their structure, and as commonly described 
consist of a series of delicate jointed threads (mycelium) in which spores 
are developed. Hyphomycetic growth is characterized by having the spores 
naked on conspicuous threads. The fungus of thrush may be found on any 
of the mucous membranes of the body. It has also been found in various 
organs, as in the brain and the lungs, and from the surface of ulcers it has 
on rare occasions penetrated the blood-vessels and given rise to visceral 
metastasis. The usual place for it to appear, however, is the mucous mem- 
brane of the mouth. It is a local disease, and may occur in the mouths of 
healthy children as well as in those who are diseased. It is more likely, 
however, to be ingrafted upon a diseased than upon a healthy mucous mem- 
brane, in accordance with the rule which I have already stated. A catarrhal 
condition of the mucous membrane, by displacing the epithelial cells and 
thus interfering with their protection of the mucous membrane, affords the 
readiest means for the development of the fungus of thrush. It is therefore 
more likely to be found in the mouths of children who are suffering from 
various diseases or who are ill cared for. It may be carried to the mouth 
in various ways, either on dirty nipples or by the finger. 

Pathology. — The growth may take place on both squamous and 
cylindrical epithelium. According to Forchheimer, the first lodgement of 
the fungus comes between the epithelial cells of the mouth, and from this 
the growth works its way under the free surface of the mucous membrane. 
When directly on the free surface the growth is not so luxuriant and is 
principally in the mycelium form. In the case of a mucous membrane 
lined by flat or squamous epithelium, the growth is facilitated by the rela- 
tion of the cells to one another. In a membrane lined by cylindrical epi- 
thelium the growth takes place, but not so readily, because there is but one 
layer of cells. After the first development the growth goes on very rapidly, 
and after it has found a nidus the cells are pushed aside and are surrounded 
by mycelium, the whole presenting the cliaracteristic appearance of thrush. 
The growth begins in small spots, sometimes one, sometimes more, and at 
times the entire surface of the mucous membrane is covered with it. The 

50 



786 PEDIATRICS. 

fiingus develops within the epithelium, and it requires considerable rubbing 
to remove the growth from the mucous membrane. 

Symptoms. — An attack of thrush usually begins with local symptoms 
of catarrhal stomatitis. At times, however, no symptoms are present, the 
fungus being the first abnormal condition which is noticed. The appear- 
ance of the fungus resembles closely that of curdled milk, though it is 
often of a rather grayish color. It does not look like a membranous exuda- 
tion, but is raised in small patches above the level of the mucous membrane. 
The fungus usually develops on the inner borders of the lips, on the gums, 
on the tongue, and on the hard and the soft palate. It may extend to the 
tonsils and pharynx, and even into the oesophagus. In the latter locality 
at times it has been found to grow so thickly that the lumen is almost 
entirely occluded. The local symptoms are commonly those of a mild 
catarrhal stomatitis. The general symptoms depend upon the extent of the 
local disease from which the infant is suffering. Infants affected with this 
disease soon become atrophic, from a lack of proper nourishment, as they are 
often unwilling to take their food or cannot swallow it without difficulty. 

Diagnosis. — The differential diagnosis is seldom difficult to make. 
Curdled masses of milk on the inner surfaces of the lips and on the gums 
may resemble closely the fungus of thrush, but the former is easily wiped 
away, while the latter is difficult to dislodge. The disease is definitively 
determined by placing some of the growth under the microscope, where it 
presents characteristic appearances which I shall presently show you. 

Prognosis. — The prognosis of thrush varies according to the general 
condition, the vitality, and the age of the subject on whom it is engrafted. 
The disease may last indefinitely if the mouth is not carefully treated, and 
its prolongation may render the prognosis more grave. Where the growth 
is very extensive, as in the cases where it has invaded the oesophagus, the 
prognosis is very unfavorable. In these cases disturbances of the gastro- 
enteric tract are apt to arise and to increase the likelihood of a fatal issue. 
As a rule, however, if the infant's health can be maintained, and if the 
local treatment is carried out thoroughly, the prognosis is favorable. 

Treatment. — The treatment should be directed to the local care of the 
mouth and to supporting the strength by proper nourishment and stimulants 
until the fungus has been eradicated. Care should be taken that everything 
connected with the infant, especially the nipples and bottles from which it is 
to be fed, should be aseptic, so that it shall not be continually reinfected or 
infect other children. The mouth after each feeding, and also between the 
feedings, should be thoroughly and somewhat vigorously rubbed with the 
solution (Prescription 74, page 779) which I have already recommended in 
the treatment of stomatitis catarrhalis. 

Where the disease is in the oesophagus it is best treated by the introduc- 
tion of a soft rubber tube, in order that the growth may thus be mechani- 
cally separated from the mucous membrane. 

In many cases the disease is very intractable. No special drug appears 



DISEASES OF THE MOUTH. 



787 



to be of use in these cases, and they can be cured onlj by the unremittmg 
and patient removal of the gro\\i;h as I have just described. 

I have here an infant (Case 391, Plate YIII., facing page 781, Thrush), three months 
old, who has refused to take the bottle for the past month, is emaciated and fretful, and at 
times vomits. 

A careful physical examination fails to detect anything abnormal except in the infant's 
mouth. On gently depressing the tongue and lower jaw, it is seen that the soft and the hard 
palate, the tongue, the gums, and the inner surface of the lips are covered almost entirely 
with white and grayish- white masses, in texture somewhat resembling curdled milk, and 
rising above the level of the epithelium. Between these patches the mucous membrane is 
reddened. There is a moderate flow of saliva. This morbid growth apparently does not 
extend into the pharynx. On endeavoring to remove one of these patches you see that 
it cannot be done readily, as would be the case if it were curdled milk, but that it has 
evidently passed between the epithelial cells down to the underlying mucous membrane, 
where it is held so closely that it requires considerable rubbing to separate it. In this case 
the growth is so extensive that it simulates a membrane in some places, but its generally 
roughened surface, its elevation above the level of the mucous membrane, and the charac- 
teristic appearances in other parts of the mouth render its recognition quite easy. 

On placing some particles of this growth in glycerin under the microscope (Fig. 98), 
you see a tangled mass of fine, almost translucent, membered threads. 



Case 391. Fig 




Mycelium of thrush interspersed with spores and fatty degenerated cells. 

Objective DD, glycerin.) 



(Low power Zeiss Oc. 3, 



Interspersed among these are bright, glistening, oval bodies, which are the formed 
spores, and also fatty degenerated cells and fine detritus. This combination of appearances 
represents the pathological processes which we find in thrush. 

Under this second microscope (Fig. 99, page 788) you will see some shreds from the 
same specimen, but much more highly magnified. 

In this specimen you can see the formation of the spores in the mycelium. 

Under this same heading of stomatitis mycetogenetica I shall merely 
refer to those pseudo-membranous conditions which occur in diphtheria, 



788 



PEDIATRICS. 



tuberculosis, syphilis, and diseases of a like class. The former two are so 
rarely seen in the mucous membrane of the mouth that it is not necessary to 
describe them. The lesions which occur in the mouth in syphilis I have 
already described when speaking of that disease (page 494). 



Case 391. Fig. 99. 




Thrush showing the formation of spores in the mycelium. (Zeiss Oc. 3, homogen. immer. 2.0 mm.) 



Stomatitis Gangrenosa (Noma, Cancrum Oris). — Stomatitis gan- 
grsenosa is the rarest and most fatal form of stomatitis which occurs in 
children. It is usually met with between the ages of three and seven years. 
It is a disease characterized by a gangrenous process which begins on the 
gums or on the inner surface of the cheek and spreads with great rapidity 
to the adjoining tissues, all of which can be involved and quickly destroyed. 

Etiology. — It is probable that there is a specific germ which causes 
this disease. This organism has, however, not yet been determined. It is 
supposed that it does not attack a healthy mucous membrane, and that one 
of the other forms of stomatitis, especially stomatitis catarrhalis, and in 
some cases stomatitis ulcerosa, precedes it. Furthermore, stomatitis gan- 
grsenosa seldom attacks healthy children, but usually affects those who have 
other diseases and are greatly debilitated. It occurs most commonly second- 
arily to the acute exanthemata, especially measles. The disease is also said 
to result from the administration of mercury in too lar^e doses. 

It begins as a reddened, hard spot in the mucous membrane, usually of 
the cheek. This soon becomes gangrenous and extends rapidly through 
the entire thickness of the cheek, producing perforation. It may also 



DISEASES OF THE MOUTH. 789 

extend laterally in all directions, attacking the bone as well as the other 
tissues. 

Symptoms. — The first symptom which is apt to be noticed is the gan- 
grenous odor which comes from the mouth. On examination an ulcer will 
be found which tends to spread rapidly. The cheek becomes much swollen, 
is hard and oedematous, the oedema especially affecting the tissues under the 
eye. The gangrenous process extends very rapidly, at times destroying large 
portions of the face, and also involving the bones, which become denuded. 
The teeth become loose and fall out. The odor from the gangrenous tissue 
is excessive. The flow of saliva is very much increased. The degree of 
suffering which the children undergo varies very much : sometimes it seems 
as if they suffered no pain whatever. The temperature varies, at times 
being raised and again being subnormal. The pulse is weak and rapid. 
The appetite is diminished, and the children are likely to have diarrhoea, 
probably due to the infectious nature of the products of the mouth which 
are swallowed. Hemorrhages are rather rare, according to Forchheimer, as 
the blood-vessels are usually filled with thrombi. Secondary affections, 
such as catarrhal pneumonia from the inhalation of septic material, are 
not uncommon. The child may die from one of these secondary affec- 
tions, or it may become more and more weakened by the local condition, 
and unless the morbid process is arrested it will die eventually from ex- 
haustion. 

Diagnosis. — The diagnosis of this disease, except in its earlier stages, 
is not difficult. At times, however, a local ulcerative process produced by 
a decayed tooth may simulate closely stomatitis gangrsenosa. In these cases 
the diagnosis is made more difficult by the fact that the tissues of the cheek 
may become hard and look as though perforation might take place. Co- 
incidently with this condition the ulceration of the gum and often of the 
mucous membrane of the cheek, with the foul odor which emanates from 
it, makes the similarity of the two diseases very striking. In simple ulcer- 
ation from a tooth, however, active local treatment with solutions of myrrh 
or of soda combined with frequent washing of the mouth with sterilized 
water is soon followed by marked improvement, while where stomatitis 
gangrsenosa is present the morbid process continues to extend. 

Prognosis. — The prognosis in cases of stomatitis gangr^enosa where 
they are untreated is almost universally fatal. Cases have been known, 
however, where a line of demarcation has fo-rmed around the gangrenous 
spot, granulations have arisen, and cicatrization has followed, leaving exten- 
sive scars. If the disease is treated by extirpation of the diseased structure 
in the very beginning, the prognosis becomes more favorable. Where the 
disease has perforated the cheek and the gangrenous process has become 
extensive, the child is seldom relieved even by surgical treatment. 

Treatment. — Care should be taken when a child is affected with a 
disease of an exhausting nature that its mouth is kept thoroughly cleansed, 
for we can never tell when or in what individual the mucous membrane 



790 



PEDIATRICS. 



may become vulnerable to the organism which produces stomatitis gangrse- 
nosa. In stomatitis gangrsenosa it is very important for the success of the 
treatment that it should be begun very early in the disease. Where the 
diagnosis has been definitively made, it is wiser not to temporize with appli- 
cations of nitrate of silver and other drugs, but at once to place the case in 
the hands of a surgeon and have the entire area of the invaded tissues 
excised. It is also well after the gangrenous process has been removed by 
the knife to destroy an area of healthy tissue by means of the Paquelin 
thermo-cautery or by the galvano-cautery. There should be no delay in 
operating upon these cases, as great destruction of the tissues may take place 
in even a few hours. 

After the operation the tissues should be inspected frequently, to see 
whether there is any return of the gangrenous spots, and, if found, these 
spots should be removed immediately. As the disease is very apt to return, 
plastic operations to obviate deformity should not be undertaken very early 
after the operation. 

In treating these cases sargically it must be remembered that the child 
is in a very debilitated condition, and that if it is suffering from any especial 
disease treatment directed to that disease is indicated, also that stimulants 
are required to prevent the already weakened child from dying of exhaus- 
tion following the operation. 

Here is a little girl (Case 392), four years old, who has been brought to the hospital to 
be operated on for stomatitis gangrgenosa. 




stomatitis gangrienosa, left cheek (before operation). Female, 4 years old. 



In this case the disease was apparently primary, and began on the the left side of the 
mucous membrane of the mouth. It spread rapidly, and, although treated by local appli- 
cations to the mouth with various solutions, has now, as you see, broken through the left 
cheek close to the ala nasi. The teeth are loose in the middle of the upper jaw, and there 



DISEASES OF THE MOUTH. 



791 



is a certain amount of alveolar necrosis. There is a strong gangrenous odor from the mouth 
and the tissues of the cheek, and a considerahle flow of saliva. The child's general condi- 
tion is fair, but she is becoming more debilitated, has lost her appetite, and has a slightly 
raised temperature. The operation should be performed immediately. 




Stomatitis gangrsuo^a. left cheek (after operation) 



(Subsequent history.) The cheek ^Yas operated on the day after the child entered the 
hospital, by Dr. H. TV. Gushing. The wound healed readily, and this picture (II.), taken 
some months afterwards, shows the scar on the cheek close to the ala nasi and also on the 
upper lip. 

Case 392. 
III- 




Storaatitis gangi-n^nosa right cheek (before ojieration). 

One year later the child again returned to the hospital, and on examination was found 
to present the appearances which are seen in this picture (III.)> taken at that time. 



792 PEDIATRICS. 

The right cheek was much swollen and indurated, especially under the right eye. The 
periosteum of the lower jaw on the right side was found to be affected, and the necrotic 
process had undermined the whole cheek as far as the orbit. The child was operated on by 
Dr. Bradford without any external opening of the cheek. The wound healed, and the 
child was discharged from the hospital, but returned some months later with a spontaneous 
opening on the right cheek. This was again apparently cured by operation. Two months 
later the child was found to have in the lower jaw a process similar to that which had oc- 
curred in the upper jaw. Her health was poor, she was pale and weak and had loss of 
appetite. She was operated upon again, and a sequestrum was removed from the lower 
jaw. She then improved, and this picture {lY.) was taken some months later, when she 
was apparently in fair health. 




Stomatitis gangraeuosa, right cheek (after operation). 

The microscopic examination of the gangrenous tissues removed at the operation 
presented nothing significant of any especial disease, and a culture made by Dr. Stone 
showed only a few streptococci. 

You will remember the case of measles (Case 257, page 587) complicated by stomatitis 
gangrenosa which I showed you at a previous lecture, and the result of which I now 
report to you. 

As I told you at that time, the disease was preceded by pertussis, measles, and a 
broncho-pneumonia. After she had the pneumonia for seventeen days her right cheek 
began to swell and a bad odor to come from her mouth, but nothing especial could be found 
in the mucous membrane of the buccal cavity. Four days later the swelling of the cheek 
had much increased, and there was oedema of the lips and eyelid so that the right eye was 
partly closed. The swelling was semi-fluctuating. The temperature varied from 38.3° to 
39.4° C. (101° to 103° P.), and the cough had much lessened. On the following day a 
bluish-black spot about 1.5 cm. (f inch) in circumference appeared at the right corner of 
the mouth, and this rapidly increased during the day. Two days later the dark-colored 
area had increased considerably in size and presented a circular outline with a clearly 
marked line of demarcation. 

The child also had a profuse greenish diarrhoea. On the following day the dark area 
rapidly extended, and soon involved the whole of the right cheek, the right side of the 
mouth, and the right nostril. There was no external loss of tissue. The child was 
extremely emaciated, and from the beginning of th.e attack was in a hopeless condition, so 



DISEASES OF THE MOUTH. 



793 



that radical treatment of the disease was deemed inadvisable. It died suddenly on the 
following day. 

Case 257. 




Stomatitis gangraenosa secondary to measles and pneumonia. Female, 5 years old. 

GLOSSITIS. — Glossitis is so rare a disease in children that the pos- 
sibility of its occurrence only need be mentioned. In this aifection there is 
an acute inflammation of the tissues of the tongue, accompanied by fever, 
enlargement of the organ, and considerable pain. There is usually a hyper- 
secretion of saliva, and at times the obstruction of respiration from the 
occlusion of the throat by the greatly enlarged tongue produces somewhat 
alarming symptoms, though, as a rule, not serious ones. 

This disease may be caused by direct injury to the tongue from corro- 
sive substances, by heat, or by the stings of animals, and sometimes probably 
by sepsis. It runs a variable course ; it is not especially serious, and tends 
to recover after a few days. The treatment is purely symptomatic. The 
frequent local application of ice and of ice-cold alkaline solutions to the 
tongue and mouth is indicated. 

A condition of the dorsum of the tongue is sometimes met with which 
for want of a better name is called lingua geographica, " mappy tongue," or 
" wandering rash." One or more small patches appear on the dorsum or 
side of the tongue, which in a few days may spread and coalesce, covering 
often a large portion of the surface. They diminish in size or fade Avith 
equal rapidity, to recur at variable periods. The patches are red and 
smooth, and the filiform papilke are absent. The rest of the tongue appears 
normal, except that the papillae on the borders of the denuded portions are 
white and prominent. The etiology of the disease is unknown. It occurs 
almost exclusively in children or in young adults who have been subject to 
it from childhood. It is very benign, and gives no discomfort to the chiki. 
Its principal importance lies in the fact that it is sometimes mistaken for a 
symptom of some more serious disease. No form of treatment has been 



794 PEDIATRICS. 

found useful. It recurs periodically for months or years, but does not tend 
to increase in severity nor to lead to other diseases. 

MICROGLOSSIA. — In some individuals an arrest of development of 
the tongue produces the condition called microglossia, in which the tongue 
is to a varying degree smaller than normal. 

MACROGLOSSIA. — The opposite condition, macroglossia, in which 
the tongue is enlarged, is more common than microglossia. It is usually 
a congenital lesion, and is especially marked in cretins. The prominent 
feature of the affection is a prolapse of the tongue, which is often enor- 
mously enlarged in every direction, is usually of a deep violet color, and 
is covered with a thick, whitish coat. The protruded tongue is indented 
and even ulcerated by the teeth, which are often pushed forward and become 
carious. The saliva flows continuously from the mouth, the lower lip 
becomes thick and ulcerated, and the forcing forward of the lip, larynx, and 
velum palati by the weight of the tongue renders suction, mastication, and 
deglutition difficult. The nutrition of the child is thus much interfered 
with, and this interference is one of the most serious results of the disease. 
This condition is not a glossitis, but a deformity which seems to be associ- 
ated with certain other malformations of the body. In these individuals 
the hands and feet are apt to be large, thick, and purplish. 

Macroglossia appears in two forms. One -is the fibrinous, in which the 
connective tissue is pathologically increased between the muscular fibres. 
The other is a cavernous cystoid degeneration of the interstitial connective 
tissue, by which the resulting spaces come into connection with the lymph- 
vessels, constituting a condition closely resembling cavernous angioma, from 
which it receives its name of lymphangioma cavernosum. 

The disease seldom tends to recover, and the treatment is to give as 
much relief as possible to the great discomfort which arises from it, by 
cleansing the mouth frequently with alkaline solutions. Especial care 
should be directed to the nourishment of the child. In extreme cases 
surgical interference is indicated where the child's respiration and general 
nutrition are affected, and in some cases great improvement is accomplished 
by the removal of part of the tongue. 

DIFFICULT DENTITION.— I have already described to you the 
process of the normal development of the teeth in infancy and child- 
hood, and have impressed upon you that this process is a physiological 
one. The teeth are developed at birth to a certain degree, and merely in- 
crease in size during infancy until they pierce the gums and assume their 
places in the mouth. In many cases the process of dentition gives rise 
to no morbid conditions whatever. The idea that dentition occasions the 
various diseases with which it was formerly supposed to be associated is an 
erroneous one. From the fourth or fifth month, however, until the com- 
pletion of dentition in the latter part of infancy, various nervous disturb- 
ances are so closely associated with irritation in the mouth that in this 
sense dentition may be considered responsible for many of the slight ail- 



DISEASES OF THE MOUTH. 



795 



ments which arise at this period of life. The mouth at this time frequently 
becomes hot, and sometimes dry, although there may be a hypersecretion 
of saliva. There is evidently much discomfort in the region of the gums, 
as the infant is continually rubbing them with its fingers and seems to get 
relief from biting on hard substances. Such infants may become much 
prostrated and may lose their appetite, and thus their nutrition may be 
interfered with, without any discoverable cause for these abnormal condi- 
tions beyond the general nervous irritation which arises from the feeling 
of discomfort in the mouth and head. In the more extreme cases the 
infant will be so restless at night that it scarcely lies still for half an hour 
at a time, and may spend night after night crying out occasionally as 
though in pain, and knocking its head against the sides of its crib, so that in 
some cases the crib will have to be padded. These infants also have to be 
guarded sometimes from knocking their heads against the floor or wall, as 
they seem to become almost frantic from the continued irritation from which 
they are suffering. These symptoms occur with such regularity at a time 
when a tooth is in its final stage of development, and cease so uniformly 
when the tooth has attained its growth, that the causal relation between the 
tooth and these nervous symptoms seems more than probable. This rather 
indefinite clinical association of dentition and nervous symptoms is, how- 
ever, partially explained by the analogous symptoms arising from the ana- 
tomical relationship which exists between the roots of the teeth and the ear. 
It has long been noticed that in certain individuals during the completion 



DIAGRAM 10. 







A, sympathetic ganglion ; B, sensori-motor nerve ; C, afferent sympathetic fibres from sheath of B ; D, 
caudate cells ; E, efferent sympathetic fibres proceeding to artery/; F, artery dilated ; /, normal size 
of artery beyond the sympathetic influence ; G, general vaso-motor centre ; H, H, the dotted lines in- 
dicating the course of the fibres forming the roots of the ganglion in the spinal cord to the general 
vaso-motor centre G. (Woakes.) 

of the development of a tooth symptoms connected with the ear will mani- 
fest themselves. These symptoms are usually produced by congestion of 
the blood-vessels of the ear, which is accompanied by pain, and sometimes 
results in inflammation. They are evidently of reflex origin. If you will 
study this diagram (Diagram 10) you will understand the influences which 
an irritation of some distant part of the economy may exert on the blood- 
vessels of the ear. 



796 PEDIATRICS. 

The general vascular disturbance in the ear, represented either by an 
uncomfortable feeling of fulness or by general pain, may be produced in 
cases of difficult dentition by this close connection between the sensori-motor 
nerves and the sympathetic. According to Woakes, a considerable portion 
of the blood-supply of the membrane of the drum is derived from the 
artery that leaves the internal carotid in the carotid canal and proceeds by a 
very short course directly to its destination. Being thus closely connected 
with a large arterial trunk, this small tympanal branch is very favorably 
situated for a speedy augmentation of its blood-supply. The nervi vasorum 
constituting the carotid plexus at this part of its course come largely from 
the otic ganglion. On the other hand, the inferior dental nerve supplying 
the gums and the teeth also communicates with this ganglion. 

We thus arrive at a direct channel of nerve communication between the 
source of irritation in the mouth and the vascular supply of the drum-head. 
The earache which arises in these cases is produced by the vessels of the 
membrana tympani, which become greatly distended, and the accompanying 
stretching of the tense and sensitive tissue in which this occurs accounts for 
the pain. 

I have represented in this diagram (Diagram 11) the anatomical nervous 
connection between the teeth and the membrana tympani. 

DIAGRAM 11. 

\ 




"■0 



A, tympanic cavity ; B, otic ganglion ; C, tooth ; D, internal carotid ; E, tympanal branch ; F, auriculo- 
temporal nerve ; G, auricular branch of auriculo-temporal nerve. 

You will thus see that a great many symptoms, usually of slight import, 
but marked enough to give much discomfort to the infant, may arise during 
this period of dentition, when the infant's entire nervcms system seems to be 
in a very sensitive condition. 

Gum-Lancing. — The question of lancing the gums during the period 
of dentition is one which has given rise to much discussion and to very 
diverse opinions. In former times it was erroneously believed that the 
teeth played an important part in almost every disease which occurred in 
early life. It was also supposed that lancing the gum relieved the symp- 
toms of these diseases in some unexplained way. This extreme view soon 
had to be modified, and of late years many observers have come to the 



DISEASES OF THE MOUTH. 797 

conclusion that it is never necessary to lance the gums. In cases of difficult 
dentition, however, as I have just explained, irritation arises very com- 
monly in the later stages of the development of a tooth, and the question, 
therefore, remains whether this irritation in various parts of the economy, 
notably in the ear, can be relieved by lancing the gum. With regard to the 
C[uestion of gum-lancing, it may be said that it should be resorted to only 
under very exceptional circumstances. 

During the dental period two classes of irritation are met with in con- 
nection ^ith the teeth : (1) irritation of the dental nerves, with symptoms 
of reflex aural disturbance ; and (2) irritation of the gum over the crown 
of the tooth from pressure, with symptoms of local irritation. We here 
have two entirely different conditions. If, where pain or symptoms in some 
other part of the economy seem to arise from dental irritation, we find that 
the gum which covers the crown of the still undeveloped tooth is soft and 
flat as in other parts of the mouth where a tooth is not about to come 
through, lancing the gums is manifestly absurd, as there is evidently no 
reason for making a wound in the mouth. 

The second class of cases, however, though exceedingly rare, must still 
be recognized as distinct in tliemselves and requiring especial treatment. In 
this class it is very evident that the gum for some reason does not give way 
to the gro^i:h of the tooth. Where the gum covers the crown of the tooth 
the tissues are swollen, tense, almost cartilaginous in their feeling, and hot. 
As in like conditions, either in the mouth or elsewhere, when this combina- 
tion of abnormal conditions is found over the crown of the tooth, it can be 
relieved at once by the lancet. 

I have here two diagrams which represent the condition of the gums in 
relation to the teeth in the two classes of cases which I have just mentioned. 
In this first diagram (Diagram 12) you see that the mucous membrane over 
the crown of the tooth is flat and on a level with the rest of the gum. 




D 
A, tooth in bone socket ; B, jaw ; C. gum, soft, not inflamed or swollen ; D, dental nerve. 

This is the condition of the gum in the majority of cases of difficult 
dentition, yet very severe symptoms of disturbance of the ear and cerebral 
circulation may apparently arise in these cases. The symptoms, of course, 
are very varied, the most definite ones being connected with the ear. In 
this class of cases the gum should never be lanced, even for the purpose of 
bleeding, as the mouth is not a fit place for such a procedure. The treat- 
ment of these cases should be directed to the especial part of the economy 
from whicli the symptoms arise. For instance, if the ear is affected, the 
indication is to relieve the reflex congestion. This can be done by the instil- 
lation into the ear of a few drops of an atropine solution (Prescription 75). 



798 



PEDIATRICS. 



Prescription 75. 



Metric. 



Gramma. 
0!06 



Apothecary. 



R Atropinse sulphat gr. i 

Glycerini, 

Aq. destil aa 3!. 



R Atropinse sulphat 

G-lycerini, 

Aq. destil aa 3 75 

M. M. 

Sig. — Drops for aural congestion. 

In addition to this, bromide of potassium should be given in repeated 
doses to the extent that is indicated by the especial case. 

In this next diagram (Diagram 13) you will see that the mucous mem- 
brane covering the crown of the tooth is markedly raised above the level 

of the gum. 

DIAGEAM 13. 

C 



^^ms^ 



Fig. 100. 



A, tooth in bone socket ; B, jaw-bone ; C, gum, tense, inflamed, swollen ; D, dental nerves. 

In these cases, symptoms of local origin and often of great severity 
arise. The infant evidently has extreme pain and tenderness in its mouth. 
It cries incessantly, and often refuses to take its nourishment, on account of 
the acute pain which it suffers, and also of the tenderness which is produced 
by the least pressure on the gum, so that it may become 
weak and exhausted. There is usually a considerable 
heightening of the temperature, to 38.8° C. and even 39.4° 
and 40° C. (102°, 103°, and 104° F.). Vomiting is not 
uncommon, and there is twitching to such an extent that 
convulsions seem to be threatening, and at times actually 
occur. There are also great restlessness and insomnia. 

In these cases lancing the gum produces immediate relief. 
The temperature quickly goes down, the pain and general 
nervous symptoms disappear, and the infant after sleeping 
quietly for an hour or so wakes up very hungry and takes 
its food with avidity. The treatment in this class of cases, 
when the diagnosis is once made, is evidently to lance the 
gum. This is done in the following way. The infant is 
placed in the nurse's lap, with its head in the lap of the 
physician, the nurse holding its arms firmly. The physician, 
after having first thoroughly sterilized his hands and washed 
the infant's mouth and gums with sterilized water, carefully 
makes an incision over the swollen gum well down to the 
crown of the tooth. I have here a lancet (Fig. 100) which 
I am in the habit of using for this purpose. 
As only the end of this lancet is sharp, there is less danger of wounding 
the infant's lips and mouth than when using the ordinary bistoury. Before 
using the lancet it should be thoroughly sterilized. 




Gum-lanret. 



DISEASES OF THE MOUTH. 799 

Although much has been said about the danger of hemorrhage in these 
cases^ and of infection of the wound by pathogenic organisms, yet instances 
where such results have occurred are so exceedingly rare that they should 
not deter us from treating the case properly as we would treat an abscess 
in the mouth, tonsil, or pharynx. It has also been said that a cicatrix may 
form on the gum over the crown of the tooth as a result of lancing. This 
is an exceedingly rare occurrence, and need scarcely be taken into account. 
The probability is, where such an instance has occurred, that the case was not 
one in which the gum should have been lanced, and the fear of such a result 
as this should certainly not weigh in the balance against the possible exhaus- 
tion and acute pain which may continue for days unless relief is given by 
cutting. 

I have a number of cases to show you which will serve to illustrate 
what I have endeavored to impress upon you in speaking of difficult denti- 
tion^ — namely, that the indications for lancing the gums very seldom arise. 

This infant (Case 393), ten months old, has been brought to the clinic with the follow- 
ing history : 

It has one lower incisor. At the time when this tooth was about to appear above the 
margin of the gum the infant was very restless, and had considerable fever, and pain in its 
ear. Somewhat later a muco-purulent discharge came from the ear, but the general symp- 
toms of restlessness, pain at times, and the local symptoms of heat and irritation in the 
mouth continued until just before the tooth had pierced the gum. After that time, which 
was three weeks ago, the discharge from the ear ceased, and the infant became perfectly 
well, the local irritation also, having disappeared. 

During the last three or four days, however, the same symptoms have returned. The 
infant is evidently suffering from irritation in its mouth. Sometimes the gums are hot and 
dry, and again there is a hypersecretion of saliva. It continually puts its finger to the 
gum of the lower jaw, sometimes almost locating it near the place where the first tooth has 
been cut. The ear has begun to discharge again, and the infant shows signs of general 
discomfort by rubbing its nose and head continuously and at times crying out as though in 
pain. 

On examining the gum you see that it is not swollen, and that there is no especially 
tender point. On examining the ears an old perforation of the membrana tympani is found 
in the right ear, which is discharging, while in the left ear there is a simple congestion. 

Such cases as this are often treated by lancing the gum, yet this procedure is not of 
the slightest use, — is, in fact, contra-indicated, as it will only increase the already existing 
irritation of the mouth. The treatment is the internal administration of bromide of potas- 
sium and appropriate local treatment for the ear. 

The other cases are so similar and are so commonly met with that I 
need not dwell upon them, but shall report one of the rare cases in which 
lanciijg of the gum is indicated. 

An infant (Case 394), eight months old, and in good health, cut its first tooth when it 
was seven months old. At this time there were no nervous disturbances, the tooth coming 
through the gum without any reflex or local symptoms whatever. 

When the second tooth was pressing on the gum I was called to relieve the following 
symptoms. The infant, who had been perfectly well, and who on examination showed no 
disease of any organ, was reported to have been feverish, restless, and crying out with pain 
for the previous twenty-four hours. It had refused to nurse, had not slept for thirty-six 
hours, had vomited a number of times, and was found to have a temperature of 40° C. 



800 PEDIATRICS. 

(104° F.). It twitched from time to time, and apparently was in danger of having general 
convulsions. On examining the mouth I found that one of the lower middle incisors was 
entirely through the gum. The gum next to this incisor was greatly swollen, tense, 
cartilaginous in feeling, hot, and tender, so that whenever it was touched the infant 
screamed with pain. I then lanced the gum. The expression of pain, which had been 
most marked on the infant's face, disappeared immediately, and was replaced by an ex- 
pression of perfect tranquillity, and it was evident that the severe pain had been relieved 
instantaneously. The infant went to sleep at once, and slept two hours. When it awoke 
its temperature was normal, it took the breast with great eagerness, and from that time it 
had no more trouble in its mouth. All the rest of its teeth were cut without any abnormal 
symptoms. 

I have also to report to you another instance which illustrates to a still 
greater extent the necessity of lancing the gums in certain cases. 

An infant (Case 395) began to have irritation from its teeth when it was five months 
old. At this time it woke up in the night screaming, and continued to scream with pain 
for several hours, during which time its parents had to walk continually up and down the 
room with it. Various remedies were administered, but without the slightest relief, and 
finally, after two days of suflering, in which it refused to take its nourishment, it lost in 
weight, .and seemed very ill. An incision was made over the hot and swollen gum, with 
immediate relief. 

The same symptoms occurred when the next tooth appeared beneath the surface of the 
gum, but were relieved, after waiting for a few hours, by lancing. Of the remaining 
eighteen teeth, six or eight gave rise to similar symptoms, but in every instance immediate 
relief was afforded by the lancing of the gum. 



DISEASES OF THE NOSE, NASO-PHARYNX, AND PHARYNX. 801 



DISEASES OF THE NOSE, NASO-PHARYNX, AND PHARYNX. 

NOSE. — The nose is the normal passage for the entrance of air to the 
lungSj and it is principally here that the air is modified before entering 
them. In normal respiration the mucous membrane of the nasal cavities, 
on account of the peculiar shape of the turbinated bones, presents a large 
surface to the inspired air, and is therefore admirably adapted to filter it of 
particles of dust and micro-organisms. The air is also warmed and changed 
so that before it reaches the larynx it is saturated with moisture and heated 
to a temperature of 35° C. (95° F.). This modification of the air is espe- 
cially important in the new-born, since the lung has so lately been brought 
into use and is in such a comparatively undeveloped condition that it can- 
not withstand unchanged air, to which it adapts itself better later in life. 
I have already described to you (page 33) the extremely narrow passage 
through which the air passes in going to and through the naso-pharynx in 
young infants, and how easily this passage can become occluded. There 
are not many diseases which occur in the nose in infants and young children, 
and those which we find are serious chiefly by being the cause of occlusion. 
In case of mouth-breathing due to nasal occlusion in an infant, the air which 
has not been modified by passing through the nose and naso-pharynx may 
have a detrimental influence on the lung and general circulation, thus strik- 
ing a serious blow at the infant's vitality. In later childhood, although the 
occlusion which arises in the nares may not be so serious as regards the life 
of the patient, yet you will see the results of such a condition represented 
by retarded development of the child and interference with the function of 
hearing, with its resulting mental dulness. 

The most common pathological condition which occurs in the nose in 
infancy and childhood is some form of rkinitis. This may be acute or 
chronic, catarrhal or purulent, hypertrophic or atrophic. JSTew growths are 
rare. Of these the more common is myxoma or simple mucous polypus. 
Bleeding from the nose, called epistaxis, may arise from an ordinary non- 
inflammatory condition, and is generally due to the breaking of a superficial 
vessel on the septum. 

Acute Rhinitis (Acute Coryza). — Acute rhinitis is an inflammatioD 
of the mucous membrane of the nasal cavities. The cause of the disease in 
most cases is apparently undue exposure to cold, though it may be proved 
eventually that this exposure merely prepares the way for the attack of 
some micro-organism. This condition may in almost all cases be con- 
sidered as part of a disease which affects the mucous membrane of the 
naso-pharynx and pharynx as well as the nares. 

51 



802 PEDIATEICS. 

The symptoms are a seuse of fulness, burning, and dryness in the 
nostrils, succeeded in a few hours by a serous discharge, which later becomes 
muco-purulent. There is usually a slight rise of temperature, and, although 
the general symptoms are often slight, there is commonly a very evident 
sense of discomfort, along with loss of appetite and general malaise. In 
some cases, by direct extension of the inflammation through the Eusta- 
chian tubes, an otitis media may be caused. Especially in young infants, 
the entrance of air into the naso-pharynx is blocked by the swelling of the 
erectile tissues covering the turbinates, and almost complete occlusion takes 
place. The patient is then forced to breathe with the mouth open, and a 
resulting condition of dryness of the mucous membrane of the mouth and 
throat and a choking sensation arising from it follow. The natural ten- 
dency of an infant or young child is to keep the mouth shut, so that often 
when the nose is occluded it breathes with great difficulty when asleep, and 
its face becomes congested and even cyanotic. On forcing the mouth open 
the symptoms of congestion and cyanosis disappear, and the child begins 
to snore, and breathes with comparative comfort so long as its mouth 
remains open, until the dryness of the throat wakes it up. 

The prognosis in these cases of acute rhinitis is usually good. The 
disease runs its course in a variable period of from three days to a week, 
and, unless the child is subjected to fresh exposure, it recovers entirely. 
The prognosis, however, as I have already stated, varies in accordance with 
the age of the individual attacked. The danger that a young debilitated 
infant may die from exhaustion where the nares are occluded is consider- 
able. You will remember the case which I described to you in a former 
lecture (page 34), where a puny, ill-cared-for infant died of a simple acute 
rhinitis. Instances of this kind should warn us that active treatment is 
indicated. 

The treatment should be directed primarily to relieving the nasal 
occlusion. This is best accomplished by atomizing the nose. In most 
cases the oil atomizer containing oleum petrolatum album is sufficient to 
afPord relief. In addition to the local treatment, the administration of 
stimulants where there is exhaustion is indicated. You should also be sure 
that the infant is taking a sufficient amount of nourishment. This is 
especially difficult to determine if it is nursing, as under these circumstances 
it will often hold the nipple in its mouth and apparently suck, while its 
breathing is so much disturbed by the nasal obstruction that it does not 
draw much milk from the breast. The various dru^s which have been 
recommended for acute rhinitis have not in my hands proved to be of 
much use. I have occasionally found that a few drops of the tincture of 
euphrasia repeated three or four times at intervals of an hour will seem- 
ingly lessen the nasal secretion. 

As an instance of this class of cases I shall report to you the case of an infant (Case 
396) who had an attack of acute rhinitis when she was four months old. Although she 
was well nourished and fairly strong, yet the occlusion of the nares, which took place 



DISEASES OF THE NOSE, NASO-PHARYXX, AND PHARYXX. 803 

rapidly, produced serious symptoms. She was somewhat cyanotic, refused to take her 
food, which had to be forced down her throat, and was sleepless, while her strength failed 
rapidly. She was cared for by a trained nurse night and day, the oil spray was used at 
frequent intervals, and stimulants were given, with the inhalation of oxygen once every 
three or four hours. Tinder this treatment she improved slowly and recovered entirely. 

In older children the serious symptoms which I have described do not 
occur, as a rule, and the disease is not much more significant than the coryza 
of the adult. 

Purulent Rhinitis. — A rather rare form of rhinitis is at times met 
with in which there have been a number of acute attacks and the process 
has become somewhat chronic. In these cases the discharge is essentially 
purulent, and the name purulent rhinitis has therefore been adopted. 

This form of rhinitis is not accompanied by any especial enlargement of 
the turbinated bodies, and narrowing of the nasal passages is not a promi- 
nent symptom. The symptoms are chiefly a purulent discharge from the 
nostrils, and redness and excoriation produced by the acrid character of the 
discharge. 

The prognosis of purulent rhinitis is good, except in extremely debili- 
tated children. 

The treatment is the same as in the catarrhal form, especial attention 
being paid to cleansing the nose with alkaline solutions and thus alleviating 
the irritation produced by the discharge. 

I have a case here in the ward which illustrates the purulent form of 
rhinitis. 

This boy (Case 397) is two and one-half years old. So far as we can ascertain, there has 
been no especial disease in his parents which would be significant in connection with the 
present condition of his nose. He is said to have been sick for four weeks. The attack 
began with fever and general discomfort in connection with the nose. Somewhat later a 
discharge began to come from the anterior nares and also from the right ear. Up to the 
time of this attack he had always been healthy and well developed, and is said to have 
been bright and to have talked as well as is usual for children of this age. During the last 
two weeks he has grown worse. There has been an increased discharge from the nares. 
He has become rather dull and apathetic, has lost his appetite, and has stopped speaking. 
The child lies in bed, or at times gets restless and sits up ; his face has a dull expression ; 
he will not speak, and he shows considerable hebetude. There is very little discharge 
from the ear, but a profuse purulent discharge from both nares. The discharge is evi- 
dently irritating, as the upper lip has become excoriated and swollen. He has now had 
the disease for five weeks. I have detected nothing abnormal in any of the organs except 
the nose. An examination made yesterday by Dr. Coolidge, one week after the child 
entered the hospital, showed that there were no adenoid growths or foreign bodies in the 
nose or naso-pharynx. The pharynx was somewhat congested, but showed no especial 
pathological condition, and the tonsils were not enlarged. The temperature has varied 
from 36.6° to 38° C. (98° to 100.5° F.). No cause has been discovered for the attack. 

(Subsequent history.) The child, under simple treatment directed to washing out the 
nose with warm alkaline solutions, and with especial attention to a nourishing diet, 
improved gradually, and three months from the beginning of the attack was discharged 
from the hospital cured. The hebetude passed away ; he talked as well as ever ; he had a 
good appetite, and a normal temperature ; the bowels were regular, and the ears, nose, naso- 
pharynx, and pharynx were in a normal condition. 



804 PEDIATRICS. 

In connection with these cases of purulent rhinitis I wish to call your 
attention to the fact that a purulent discharge from the nose may be the 
result of an unsuspected foreign body in the nasal passages. This is 
especially likely to be the case if the discharge is from one side only. It 
frequently occurs in children, as they are very apt to push various bodies 
up their noses. If the foreign body happens to be a piece of thin paper or 
other soft material, it may not cause much nasal obstruction, and its pres- 
ence may easily be overlooked even when a probe is carefully used in 
making the examination. 

Hypertkophic Rhinitis. — This form of rhinitis is rare in infancy 
and childhood, and I shall therefore merely refer to it. Rhinitis is spoken 
of as hypertrophic when in addition to a chronic inflammation of the 
mucous and submucous tissues of the nose there is an actual hypertrophy 
of the mucous membrane, which results in occlusion of the nares and con- 
sequent interference with respiration and the removal of the normal dis- 
charges from the nose. One of the most common causes of hypertrophic 
rhinitis is the occlusion of the posterior nares by adenoid growths, which 
interfere with the normal nasal secretions by retaining thenii in the nasal 
cavity and allowing them to decompose. A recurrent acute rhinitis may 
also be an etiological factor in hypertrophic rhinitis. 

The most marked symptom in hypertrophic rhinitis is the nasal obstruc- 
tion, which usually alternates from one side of the nose to the other. As 
would naturally be expected from the lesions, the symptoms are those of 
great restlessness, especially at night, and various reflex phenomena con- 
nected with the throat and the larynx. Thus, there may be continued cough, 
and, where the Eustachian tubes are occluded, deafness and a resulting 
hebetude. At times interference with speech results. There is not much 
nasal secretion in these cases, which aids us in the differential diagnosis 
from the other forms of rhinitis of which I have just spoken. 

The treatment of these cases when they are dependent upon growths in 
the naso-pharynx is the surgical removal of such growths. Mild astringent 
sprays should be used, and the oleum petrolatum spray which I have just 
recommended in catarrhal rhinitis. As a rule, these cases should be placed 
in the hands of a specialist. 

Atrophic Rhinitis (Ozsena). — By atrophic rhinitis is meant a condi- 
tion of the nose characterized by atrophy of the mucous membrane and of 
the bony prominences within the nose, accompanied by what has been termed 
a dry catarrh, as a result of which the secretion of the nose forms crusts, 
which undergo decomposition and become fetid. It is also called ozsena. 
The disease is one which attacks older children rather than infants, and its 
etiology is obscure. According to Bosworth, it arises from the purulent form 
of the disease, and he states that as long as the desquamation of epithelium, 
which is the predominant lesion of purulent rhinitis, is confined to the 
superficial epithelial cells, the disease is attended with a thick and purulent 
discharge, but sooner or later the desquamative process extends to the 



DISEASES OF THE NOSE, NASO-PHARYNX, AND PHARYNX. 805 

epithelial lining of the mnciparous and follicular glands. The glandular 
function is thus impaired, and the muco-purulent discharge becomes thick 
and firmly adherent in the form of crusts to the sinuosities of the nose. 
This film of desiccated muco-pus in drying contracts the underlying turbi- 
nated tissues in such a way as to interfere with the circulation of the blood, 
a condition which limits glandular action still more and conduces to general 
atrophy. 

The symptoms of atrophic rhinitis are the formation of crusts and the 
presence of fetor. 

Although the tissues which have actually been destroyed by the atrophic 
process cannot be restored by treatment, the patient can be entirely relieved 
of the crust formation and fetor by persistent and patient local washing and 
applications. The details of treatment differ according to the extent and 
character of the disease. Crusts may be removed by spraying or douching, 
great care being taken to prevent the washing fluid from entering the 
Eustachian tubes. If this is not sufficient to remove the crusts, the nasal 
cavities must be illuminated with a head-mirror, and the crusts carefully 
brushed off with a cotton-stick. The formation of dry, hard crusts is often 
prevented by frequent spraying with an oil. Local applications of different 
substances are of use in many cases, but these should, as a rule, be carried 
out under the direction of a specialist in the treatment of diseases of the nose. 

Mucous Polypus. — This is a pedunculated connective-tissue growth 
originating from the mucous membrane of the middle turbinate bone. It 
is rare in children. It does not grow on a healthy mucous membrane, and 
is always preceded by some morbid condition of the nose. It is often 
multiple. 

The symptoms begin with a nasal discharge follow^ed by nasal occlusion. 
The diagnosis is easily made by a mirror and a probe. The treatment is 
the removal of the growth. 

Epistaxis (Hemorrhage from the iSose). — During the period of early 
childhood hemorrhage from the nose is not uncommon. I have occasionally 
met with epistaxis in young infants, but in my experience it is rare in the 
early months of life. In older children recurrent epistaxis, especially if 
unilateral, points to the presence of an erosion or a varicose condition of the 
veins in the cartilaginous septum near the external opening of the nose. 

Unless the individual happens to be affected by haemophilia, epistaxis 
is not especially dangerous, and usually its occurrence ceases as the child 
grows older. 

The application of pressure on the side of the base of the nose and the 
use of ice are usually sufficient to stop the hemorrhage. If the epistaxis 
is due to the varicose condition just spoken of, it can be readily controlled 
temporarily by a plug of cotton pressed upon the bleeding part. For a 
permanent cure, cauterizing the bleeding part may be necessary. 

NASO-PHARYNX. — I have described in a previous lecture (page 33) 
the anatomy of the naso-pharynx. Although this cavity is small and 



806 PEDIATRICS. 

apparently insignificant, yet it plays a very important part in a number of 
the diseases to which children are liable. The condition which makes 
this portion of the respiratory tract especially important is the presence of 
the pharyngeal tonsil which lines its cavity. 

Hypertrophy of the Pharyngeal Tonsil (Adenoid Growths). — 
The glandular or lymph tissue which lines the vault and posterior wall of 
the naso-pharynx is very similar to that which composes the faucial tonsils, 
and is called the pharyngeal, third, or Luschka's tonsil, Luschka having 
first described it. Under certain circumstances this tissue becomes hyper- 
trophied, and gives rise to the condition which is usually designated as 
adenoid growths. 

Etiology. — Hypertrophy of the pharyngeal tonsil, although it may 
occur in infancy, is uncommon before the second or third year. The disease 
is essentially one of childhood, as it very seldom develops after puberty. 
Acute inflammatory conditions or some obstruction in the nose are probably 
the inciting causes of adenoid growths. 

Pathology. — The pathological condition which is found in the lymph 
tissues of the naso-pharynx is an hypertrophy which is very similar to the 
hypertrophic condition of the faucial tonsils, except that the latter contain 
a greater amount of connective fibrous tissue. The hypertrophy may be of 
greater or less extent, sometimes not being sufficient to cause any especial 
occlusion and at other times completely occluding the posterior nares. 

Symptoms. — The first and most prominent symptom which is usually 
noticed in children who have this disease is that they breathe with their 
mouths open at night and snore. As the nares become more occluded the 
child begins to breathe through its mouth also when it is aAvake. The 
interference with the proper passage of the air to the larynx and lung 
results in a chronic form of pharyngitis and laryngitis, while the blocking 
of the nasal end of the Eustachian tubes may result in a chronic catarrhal 
condition of the middle ear. Any or all of these symptoms may arise in 
an individual case according to the amount or position of the obstructions. 
The child's expression changes, and is almost characteristic when the disease 
is fully developed. It holds its mouth open, the lower jaw appears to 
drop, the lips are apt to be thick and expressionless, and when mental 
dulness is added to the other symptoms it has a stupid look. If this 
condition continues after the seventh or eighth year, the bridge of the 
nose is apt to be prominent and its sides to look pinched ; the palate 
may be markedly arched, and the upper jaw narrowed laterally so as to 
crowd the teeth. The faucial tonsils may or may not be enlarged, but are 
usually so. This enlargement of the faucial tonsils is, as a rule, secondary 
to the affection of the pharyngeal tonsil, and not its cause. 

Diagnosis. — The diagnosis of hypertrophy of the pharyngeal tonsil is 
not difficult in a marked case or if it is possible to examine the child's 
naso-pharynx. In young infants the posterior nasal space is so minute 
that it is almost impossible to reach it. The diagnosis can often be made 



DISEASES OF THE NOSE, XASO-PHAKYNX, AXD PHARYNX. 807 

simply by the appearance of the child, as there is no other disease which 
especially simulates this condition. A definite diagnosis, however, can be 
made only after the hypertrophied tonsil has actually been seen or felt. 

I would impress upon you the great importance of learning to detect by 
means of the finger the presence of an enlarged pharyngeal tonsil. This 
acquirement is necessary, not only for the purpose of diagnosticating the 
presence of this disease, but also in order to determine correctly the cause 
of many other abnormal conditions. The examination with the miiTor in 
the throat is usually so difficult in young children that the direct detection 
by means of the finger is often the most applicable means to employ in 
these cases. The child should have a blanket pinned around it tightly, so 
as to keep it from moving its arms. It should be held firmly sitting in the 
nurse's lap. You can then hold the child's head with one arm, pressing 
the cheek between the back teeth with the forefinger, then pass the forefinger 
of the other hand gently, firmly, and quickly over the base of the tongue 
and behind the soft palate until it reaches the posterior wall of the pharynx. 
Then, quickly turning the finger upward, you can easily feel whether the 
cavity of the naso-pharynx is clear or whether it is more or less filled by a 
soft, spongy mass, the hypertrophied pharyngeal tonsil. There is usually 
a little blood on the finger when it is withdrawn, as the growth is friable 
and bleeds easily. This examination is not, as a rule, very painful to the 
child, but produces a certain amount of discomfort from a choking sensa- 
tion. When the finger is once in the mouth, it is not wise to take it out 
again until you have completed your examination, as the child can rarely be 
induced to allow you to make a second examination. In passing the finger 
over the base of the tongue you must be careful to get the finger behind the 
soft palate, and not to push it upward and backward, for in this case the 
soft tissues of the palate may feel like an adenoid growth. The child can 
be prevented from biting the finger by simply keeping the cheek pressed 
between the teeth as I have just described. 

Lack of development of the chest with flattening of the front of the 
thorax may be caused, not, as was formerly supposed, by the enlargement 
of the faucial tonsils, but by the occlusion caused by the hypertrophy of 
the pharyngeal tonsil. This hypertrophy with its resulting nasal occlu- 
sion may also be the cause of pharyngitis, laryngitis, and perhaps of bron- 
chial catarrh or asthma, which can be cured only by the removal of the 
primary cause, the pharyngeal tonsil. 

In order to impress upon you the chief points in the diagnosis of these 
cases I show you this little girl. 

She (Case 398) is ten years old, and presents a typical picture of this disease. 

You see that her mouth is held open and that she evidently has complete occlusion of 
the posterior nares, the anterior nares on examination being found entirely free. You will 
notice the pinched look of the face on either side of the nose and the prominence of the 
bridge of the nose. The child is dull, the dulness having increased as the other symptoms 
of the adenoid growth have developed, and her face now has a stupid expression. When 



808 



PEDIATEICS. 



you have once seen and studied a case of this kind, you will have no difficulty in making 
a diagnosis by simple inspection. On examining the child's mouth you see that the palate 
ii very much arched, that the tonsils are enlarged, that the soft palate is slightly pushed 
forward, and that the pharynx is narrower than normal. 

(Subsequent history.) After removal of the adenoid growths and faucial tonsils by Dr. 
Coolidge she found no difficulty in keeping the mouth closed, not only while awake, but also 
at night, and slept much more quietly than before. Her general health improved, and the 
development of her face during the remainder of its growth will undoubtedly be normal. 

Case 398. 




Hypertrophy of pharyngeal tonsil (adenoid growths). Female, 10 years old. 



Pkognosis. — The prognosis of cases of hypertrophy of the pharyngeal 
tonsil varies greatly , for there are all forms and degrees of the affection. In 
some cases the swelling of the lymph-tissues occurs only at intervals when 
the child has been subjected to exposure in inclement weather ; it will then 
show itself simply by occlusion of the nares, with the resulting discomfort, 
lasting for some weeks, but disappearing eventually as the weather becomes 
milder or if the child is taken to a different climate. In most cases, how- 
ever, where the affection is at all pronounced it becomes chronic, and the 
symptoms usually increase in severity up to about the time of puberty. 
You must remember that the naso-pharynx has an important function 
besides being a passage-way for the air. It lubricates the pharynx, and by 
the action of its muscles opens the Eustachian tubes during the acts of 
swallowing and yawning, thus ventilating the ear. You will see, therefore, 
that the prognosis must vary according to the degree in which any of these 
functions are interfered with. Where the children become deaf they may 
gradually lose the power of speech. Again, from being deaf they may fall 
into a condition of hebetude which sometimes closely simulates idiocy, 
though it is not true idiocy, for the mental condition quickly changes when 
the cause of the disturbance has been removed. Where the disease is diag- 
nosticated in its early stages, or later, unless irreparable injury has been 



DISEASES OF THE NOSE, NASO-PHARYNX, AND PHARYNX. 809 

done to the ear or the general development, the prognosis is very favorable, 
provided the proper treatment is carried out. 

Treatment. — The best treatment of these cases is to remove the 
adenoid growth at once. The operation in the hands of a skilful surgeon 
is not dangerous, and should be unhesitatingly advised. There are a num- 
ber of methods which have been employed in operating on these cases. The 
child should be thoroughly etherized. Some operators prefer to have the 
child held sitting in the lap of an attendant, others to have it lying down 
with its head bent backward. The soft palate is drawn forward by means 
of a palate-hook held in the left hand. A pair of post-nasal forceps held 
in the right hand is introduced, closed, into the naso-pharyngeal cavity. 
The blades are then opened, and pieces of the mass are grasped one after 
the other and pulled off gently : under no circumstances is force to be 
exerted. With proper care and assistance there is no danger to the child, 
and often in ten or twenty minutes a morbid condition which has existed 
for years may be practically cured. There are, of course, many details in 
this operation which must be thoroughly understood in order that it should 
be successful. These details, however, need scarcely be mentioned here, as 
the operation should be performed only by one whose work has especially 
adapted him for it. 

These growths when not extensive are sometimes removed even without 
ether with the curette or the finger-nail. 

I have here a little boy who illustrates the benefit of operative treatment 
for the removal of the pharyngeal tonsil when hypertrophied. 

He (Case 399) is four years old. You see that he has a very bright expression, and he 
speaks well ; he shows nothing abnormal in connection with the shape of his nose or face. 
He hears well, he sleeps with his mouth shut, and has a free passage of air through a perfectly 
normal nose and naso-pharynx. When he was three and a half years old it was Boticed 
that he snored at night, breathed with his mouth open, and was subject to continual attacks 
of rhinitis and naso-pharyngeal occlusion. Following these attacks his hearing became 
affected, and, while in his second year he had been bright and always ready to play with his 
parents, he became dull, and did not care to play with others, but would sit for hours play- 
ing by himself with his toys. 

A digital examination showed a mass of considerable size blocking the posterior nares. 
On the removal of this mass, which proved to be an hypertrophied pharyngeal tonsil, rapid 
improvement took place in his general condition, the dulness and hebetude disappeared, 
and within the last month he has returned to the normal condition which he represented in 
his second year. 

There are other growths which occur in the naso-pharynx, such as 
sarcomata. They are, however, too rare to need especial description. 

PHARYNX. — Diseases of the pharynx in chiklren are especially those 
affecting the tonsils, the uvula, the soft palate, and the posterior wall of the 
pharynx. 

Tonsillitis. — By tonsillitis is meant an inflammation of the tissues of 
the tonsil. This inflammation may be acute or chronic. 

Acute Tonsillitis. — Acute tonsillitis may be simply an inflaniniatory 



810 PEDIATRICS. 

condition represented by enlargement and reddening, simple tonsillitis, or the 
inflammation may be especially located in the crypts of the tonsil, in which 
case it is commonly designated follicular tonsillitis. 

The other affections of the tonsils, such as occur in the course of the 
exanthemata and in diphtheria, constituting the pseudo-membranous form 
of the disease, can best be described in connection with the especial diseases 
in which they arise, and I shall therefore speak only of the two forms to 
which I have just alluded. 

Acute Simple Tonsillitis. — It is probable that the cause of the acute 
simple form of tonsillitis is a microbe. The child is usually attacked 
suddenly, with a heightened temperature, 38.8° to 39.4° C. (102° to 103° 
F.), fever, restlessness, and sometimes vomiting and loss of appetite. Young 
children do not complain of the throat so much where the tonsils are aifected 
as do older children and adults. In fact, in many cases, unless the throat is 
actually inspected, it would seem as though it were not a local affection of 
the throat, but some general disease affecting other parts of the system. 
You should be especially on your guard, therefore, not to have your atten- 
tion diverted from the throat, but under all circumstances where these symp- 
toms arise in young children, even though they apparently swallow without 
discomfort, to examine the throat before deciding whether or not some other 
disease is developing. 

- On inspection of the throat the tonsils are seen to be enlarged in different 
degrees and to be of a uniform bright red color. 

The mucous membrane of the pharynx is, as a rule, much reddened ; the 
soft palate may also be reddened, but not necessarily. The symptoms con- 
tinue for a day or two and then diminish, and the child usually recovers in 
about a week. 

The local application of a cleansing spray, and the administration of ice 
if desired to relieve the discomfort, constitute all that is necessary for the 
treatment of these cases. It is best not to disturb the mucous membrane 
with applications on swabs or brushes. 

Acute Follicular Tonsillitis. — In the acute inflammation of the tonsil 
which is usually called follicular tonsillitis, in addition to the general 
inflammation of the tonsils the crypts are especially affected. The cause 
of this form of tonsillitis is undoubtedly infection by some pathogenic 
germ. It is probable that more than one form of germ is capable of 
causing it. Many of the pathogenic germs which infest the mouth or the 
throat may be found in the crypts in this disease, but the especial germ by 
which we can characterize the disease has not yet been determined. 

Symptoms. — As a rule, the disease is characterized by an acute onset, 
with a heightened temperature, 39.4° to 40° C. (103° to 104° F.), loss of 
appetite, and general malaise. I have often noticed, however, that the symp- 
toms of a marked follicular tonsillitis are not so acute and do not so defi- 
nitely point to the throat in young children as they commonly do in older 
children and in adults. On examinino: the throat the tonsils are seen to be 



DISEASES OF THE ^OSE, XASO-PHAEYXX, AXD PHARYXX. 811 

enlarged, reddened, and in the early hours of the disease to show a little 
swelling of the orifices of the crypts, as though a secretion within them 
was about to burst the overlying mucous membrane and ajipear on the free 
surface. Later this actually occurs, and the tonsils are seen to be studded 
with white or grayish- white spots. These do not appear on the soft palate 
or uvula, though they may appear on the base of the tongue and the poste- 
rior pharyngeal walls. The mucous membrane of the pillars of the palate, 
of the uvula, and of the soft palate are usually reddened, and there is very 
apt to be decided reddening and even swelling of the mucous membrane and 
follicles of the pharynx. As the disease progresses these spots may coalesce 
and, adhering to the surface of the tonsil, form a pseudo-membrane which is 
often impossible to distinguish from diphtheria without a bacteriological 
examination. As there is a direct connection between the tonsils and the 
cervical glands, the latter are liable to be involved, though any great swell- 
ing of the cervical glands in connection with acute tonsillitis is uncommon. 

The disease is self-limited, and runs its course in two or three days or a 
week, at the end of which time the general symptoms subside, the appetite 
returns, the temperature becomes normal, and the child, although it is left 
somewhat weakened by the disease, seems as well as ever. The tonsils 
themselves, however, do not for some time regain their original size, and 
the exudation often remains in the crypts and may cause a chronic irritation 
with a tendency to recin;rence. 

Diagnosis. — The differential diagnosis of follicular tonsillitis is to be 
made from the various form.s of stomatitis, which I have already sufficiently 
described, and from diphtheria, of which I shall presently speak. It is now 
very generally kno'wn that it is impossible absolutely to exclude diphtheria 
by the morbid appearances seen on the tonsils. In the great majority of 
instances, however, where the attack is acute, where the cer\4cal glands are 
not especially involved, where the white spots on the tonsils are clearly 
located in the orifices of the crypts, and where there is no appearance of a 
membrane on the uvula or the soft palate, we can make the clinical diagnosis 
of follicular tonsillitis with considerable certainty, but never surely without 
a bacteriological examination. 

Prognosis. — The prognosis of follicular tonsillitis is in almost every 
case favorable, and is rendered unfavorable only by the complication of 
tonsillar abscess. But you must remember that in an inflamed tonsil patho- 
genic organisms, such as those of diphtlieria, are more apt to develop. 

Treatment. — The treatment of acute follicular tonsillitis, according to 
my experience, should be entirely symptomatic. It is a self-limited disease, 
and in a vast majority of cases is not benefitcil by the administration of any 
drug internally or by local applications. In order to avoid the invasion of 
the various pathogenic germs during the progress of the tonsillitis I am in 
the habit of having the throat kept thoroughly clean with mild solutions of 
chlorate of potassium or borate of sodium. Holding pieces of cracked ice 
in the mouth often affords considerable relief. In vouno^ children, as a rule, 



812 PEDIATRICS. 

I make no local application beyond allowing them to swallow cold solutions 
of chlorate of potassium in the strength which I have already advised 
(page 783). Small doses of quinine according to the age of the child are 
indicated where there is much exhaustion or malaise following the attack. 
I happen to have here in the wards a case of acute follicular tonsillitis. 

This little girl (Case 400, Plate VIII., facing page 781, Follicular Tonsillitis), four 
years old, has an attack of follicular tonsillitis and illustrates what I have just told you. 

She was taken sick two days ago with a heightened temperature of about 39.4° C. 
(103° r.), loss of appetite, and general malaise. She did not complain of her throat, and 
swallowed without difficulty. Nothing abnormal was found in any of the other organs, 
but on inspecting the throat the tonsils were seen to be enlarged and much reddened, and 
one or two of the orifices of the crypts were somewhat raised above the general surface of 
the tonsil. On the following day a number of white spots of different sizes appeared ou 
both tonsils. To-day you see that the redness is mostly confined to the tonsils, and affects 
the uvula and palate very little. On the inner surface of both tonsils the exudation has 
coalesced, so that it has an appearance very much like that of a pseudo-membrane. It is 
not uncommon in follicular tonsillitis for this coalescence of the exudation to take place on 
the surface of the tonsil which points towards the median line of the throat. The other 
appearances of the tonsils are characteristic of follicular tonsillitis. On the upper left-hand 
corner of the left tonsil, close to the arch of the palate, you will see an enlarged cryptic 
orifice which has not quite broken down, and which appears as a light red prominence on 
the general surface of the tonsils. The orifices have a like appearance in various parts of 
both tonsils. On the anterior surface of the left tonsil are two white spots, caused by the 
exudation from the crypts. In the upper part of the right tonsil are three smaller yellow- 
ish-white spots, and lower down on the tonsil a grayish-white rather large spot, all of them 
due to the same cause. There are no other lesions in the throat, and the cervical glands are 
not involved. 

Cultures made from this exudation did not show the presence of the Klebs-Loeffler 
bacillus. 

In a case of this kind, with appearances such as you see in this throat, you can say 
that the disease is probably follicular tonsillitis and not diphtheria, especially when the 
absence of the Klebs-Loeffler bacillus has been proved. 

The child now has a normal temperature, and is improving rapidly. In a few days it 
will be entirely well. The lesions, as you see, are still present in the throat, but the disease 
has run its course and has ceased to produce any general symptoms. 

The treatment has been simply to feed the child from time to time with small doses of 
iced milk. No local applications and no drugs have been used. 

Chronic Tonsillitis. — After an acute tonsillitis has recurred a number 
of times, or where a chronic form of inflammation has affected the tonsil 
from the beginning, an enlargement of the tonsils takes place, which consists 
of an hypertrophy of their tissues. This is what is known as hypertrophy 
of the tonsils. 

Although this hypertrophy of the faucial tonsils may exist without a 
corresponding affection of the pharyngeal tonsil, yet it is very apt to be 
secondary to this latter condition. 

Pathology. — The terms chronic tonsillitis and hypertrophied or en- 
larged tonsils are commonly used to express the same condition, especially 
in children, in whom chronic inflammation of the tonsils unaccompanied by 
enlargement seldom occurs. This enlargement is always due, at least in 



DISEASES OF THE NOSE, NASO-PHARYXX, AND PHARYNX. 813 

part, to true hypertrophy, generally accompanied by more or less inflamma- 
tory deposit. If the parenchymatous or glandular tissues are especially 
affected we find a soft, more or less red and vascular tonsil, with large 
crypts, often containing much secretion. In the interstitial form the tonsil 
is hard and tough, the crypts less prominent or even very small, and the 
vascularity much diminished. These types are the two extremes ; in most 
cases the enlargement is essentially one of hypertrophy. The tonsils may 
be only moderately enlarged, or their size may be so increased that they 
meet, touching each other in the median line. The growth is usually 
towards the median line. In examining a child for enlargement of the 
tonsils care must be taken that the pharynx is not contracted by gagging at 
the time the examination is made. The act of gagging, which is easily 
brought about in children by a careless use of the tongue-depressor, brings 
the tonsils towards the median line, thus giving tonsils of normal size the 
appearance of being large and obstructive. 

Symptoms. — The symptoms of hypertrophy of the faucial tonsils vary 
according to the degree of enlargement. Normally the tonsils can scarcely 
be seen on inspection of the throat. When only moderately enlarged they 
may produce no symptoms whatever beyond a feeling at times of slight 
irritation in the throat. AYhen in this condition, however, they are more 
apt to be irritated by various external influences and to be the source of 
recurrent acute affections of the throat. When considerablv enlaro^ed thev 
may still not produce any marked symptoms, provided that the passage of 
air through the naso-pharynx is unobstructed. They may, however, even 
when the pharyngeal tonsil is not enlarged, cause obstruction in the naso- 
pharynx by pressure as they enlarge upward and backward. When this 
happens, the same interference with the breathing and development of the 
child takes place as when the obstruction is primarily in the naso-pharynx. 
These symptoms are the same as I have already described in speaking of 
hypertrophy of the pharyngeal tonsil, and therefore need not be detailed here. 

Occasionally difficulty in swallowing and thickness of speech may arise 
where only the faucial tonsils are enlarged. 

Prognosis. — The prognosis in cases of hypertrophy of the faucial 
tonsils depends upon these varied anatomical conditions which I have just 
explained to you. So long as the tonsils do not encroach on the naso- 
pharynx the prognosis, so far as injury to the child is concerned, is good. 
You must always remember, however, that the enlargement of the tonsils is 
a fertile source of irritation which may prepare the way for serious disease 
produced by the various micro-organisms. The prognosis as to their disap- 
pearing is not especially good, as they seldom recover their normal size 
without active treatment when once hypertrophied, though they generally 
diminish slowly in size after puberty. 

Treatment. — Local applications for the reduction of hypertrophied 
tonsils are useless. Some success has been obtained by Gampert by wliat is 
called discission of the tonsils. Leland has sti-ongly advocateil this treat- 



814 



PEDIATRICS. 



ment, which consists in making slits in the tonsil with a knife especially 
devised by him. 

The most thorough and certain way of curing the disease is, however, 
by excision. This should be done with the tonsillotome, and it is best to 
etherize the child for the operation. It is considered wiser to amputate the 
tonsil than to enucleate it. After the operation the child should be made 
to gargle with a solution of borate of sodium for two or three days, and 
should be given only milk for its food. 

As a result of attacks of acute inflammation the hypertrophied tonsils 
may have become adherent to the anterior or the posterior pillars of the 
fauces to such an extent that the guillotine either cannot be used, or not 
without danger of wounding these pillars. In such cases it may be neces- 
sary to revert to dissection or to the galvano-cautery to remove the tonsillar 
tissue. 

I have an interesting case of hypertrophy of the faucial tonsils and of 
the pharyngeal tonsil to show you to-day. 

The child (Case 401), a boy, seven years old, has for the past two years been under my 
observation. He was a healthy infant and well developed until his fifth year, when he did 
not continue to grow normally and lost much in weight. He became rather dull, and 
although he did not have any especially severe symptoms, yet he frequently had mild attacks 
of rhinitis, pharyngitis, and tonsillitis. After a number of recurrent attacks of tonsillitis 
the tonsils remained enlarged, and for the past two years he has presented in his throat the 
condition of hypertrophied tonsils. Various applications have been made to the tonsils 
without any favorable result. The specialist who first saw the child told the parents that 
the tonsils would probably decrease in size as the child grew older, and that operative treat- 
ment would not be advisable. The child is now beginning to breathe with his mouth open 
at night, and to be very restless when asleep, and has become very nervous. The chest, as 
you see, is decidedly flattened, and the sides of the nose are beginning to look a little 
pinched. The child is evidently sufiering from obstruction to the entrance of air to the 
lungs, and I have therefore decided that operative treatment is indicated. 

Fig. 101. 






Part of the hypertrophied pharyngeal tonsil in the upper part of the figure. Excised surfaces of the 
faucial tonsils in the lower part of the figure. Male, 7 years old. 



Dr. Farlow will now examine the case before you and operate on it. On passing the 
finger up into the naso-pharynx it is found that the pharyngeal tonsil is markedly enlarged, 
and as the result of the obstruction the breathing of the child is interfered with, and also its 
development. 



DISEASES OF THE NOSE, NASO-PHARYNX, AND PHARYNX. 815 

The child is now etherized, and Dr. Farlow has first, as you see, excised both tonsils 
with the tonsillotome and has then removed the pharyngeal tonsil with the forceps. 

Here you will see the crypts and the intervening connective tissue of the excised 
faucial tonsils, and also the soft spongy tissue of the pharyngeal tonsil. (Fig. 101, p. 814.) 

(Subsequent history.) Within six months after the removal of the pharyngeal and 
faucial tonsils the boy presented an entirely difterent appearance from what he did before 
the operation. His chest had developed, he had a better color and a good appetite, he had 
ceased to be nervous, slept with his mouth closed, and showed no tendency to the recur- 
rence of the rhinitis from which he formerly suffered continually. 

Peritonsillar Abscess. — In some cases an inflammatory process 
resulting in suppuration occurs in the cellular tissue around, above, or 
behind the tonsil, constituting an abscess which is called peritonsillar. It 
is rather rare in early childhood. The disease is usually preceded by a 
certain degree of simple tonsillitis, and when it develops the temperature 
rises, perhaps to 40° or 40.5° C. (104° or 105° F.), and the child evidently 
suffers much pain. 

On inspecting the throat in these cases a unilateral swelling is seen in 
the neighborhood of the tonsil, as a rule, pushing the soft palate forward, 
and the tonsil towards the median line. 

The prognosis is in almost every case favorable, except those which 
have been neglected or improperly treated. There is sometimes extensive 
burrowing of the pus, and hemorrhage, or even oedema of the larynx, may 
occur. 

The treatment is to locate the abscess by careful palpation and to open 
it under strict antiseptic precautions with a guarded bistoury. 

Pharyngitis. — An inflammatory condition of the posterior wall of the 
pharynx is rather rare in infancy, but is not uncommon in children. It is 
usually coincident with an inflammatory condition of the naso-pharynx or 
of the tonsils, but in a certain number of cases it is so much more pronounced 
in the posterior wall than elsewhere that it can be described as a separate 
disease. The diseases of the posterior wall of the pharynx are either (1) a 
simple catarrhal condition of the mucous membrane or (2) an inflammatory 
process in which the follicles are especially affected. In addition to these 
conditions, pus may form behind the mucous membrane, producing a retro- 
pharyngeal abscess. The inflammatory lesions of the pharynx may be 
acute or chronic. 

The conditions which give rise to pharyngitis are the same various 
morbid processes that involve the parts in the neighborhood of the 
pharynx, such as the naso-pharynx and the tonsils. These causes I have 
already mentioned. There also seems to be a connection between certain 
irritations arising in the gastro-enteric tract and the pharynx. Where this 
occurs it is usually the chronic form of pharyngitis which is met with, and 
the causal connection between these two distant parts of the economy is 
probably of a reflex nature. 

Acute Simple Pharyngitis. — The pathological condition which is 
found in the simple acute form of pharyngitis is an acute inflammation 



816 PEDIATRICS. 

characterized by a slightly heightened temperature, a hypersemic condition 
of the blood-vessels of the posterior wall of the pharynx, and a certain 
amount of swelling and of serous exudation. 

The symptoms are discomfort in swallowing, and at first a feeling of 
dryness in the throat, followed later by an exudation of viscid mucus. The 
child does not seem especially sick with this disease, and the length of the 
attack varies according to the influences which are causing it. 

Acute Follicular Pharyngitis. — The acute follicular form of pharyn- 
gitis does not differ materially in its symptoms from the simple form, and in 
fact both forms are so frequently combined that a clinical distinction need 
scarcely be made between them. On examining the pharynx in this form 
of pharyngitis, in addition to the appearances which are seen in the simple 
form, the follicles will be found enlarged and raised above the surface of 
the mucous membrane. 

Treatment. — The treatment of both forms of pharyngitis is essentially 
local, and is, as a rule, by applications to the inflamed mucous membrane in 
the form of a spray, either directly, or indirectly through the nose. The 
spray is essentially for the purpose of cleansing and thus soothing the 
inflamed mucous membrane, and should consist of mild alkaline solutions 
such as this one (Prescription 76) : 

Prescription 76. 
Metric. Apothecary. 

Gramma. 

R Sodii chloridi 

Sodii bicarb., 

Sodii boratis aa 

Aquae rosae 30 

Aquse 90 

M. M. 

Sig. — Spray for pharyngitis 



3 R Sodii chloridi gr. v ; 

Sodii bicarb., 

9 Sodii boratis aa gr. xv ; 

Aquae rosae ^ i ; 

Aquae ^^iij. 



The chronic form of pharyngitis is usually accompanied by an irritating 
cough, which is most pronounced at night and in the morning. You should 
not think that these children who are coughing continuously and often 
losing in weight and looking weak and anaemic are necessarily affected 
with bronchitis. This series of symptoms is frequently looked upon as 
diagnostic of bronchitis, when it really arises from pharyngitis, and can be 
cured by treating the latter disease. 

The treatment of chronic pharyngitis is to remove any hypertrophic 
condition of the tonsils, tongue, or nose, to regulate carefully the child's 
general nutrition, and to avoid undue exposure to inclement weather or to 
air vitiated in any way, as by arsenic or dust. Local applications of a 
one per cent, solution of nitrate of silver, followed immediately by thorough 
cleansing with sterilized water, are sometimes indicated in the more intract- 
able cases. 

Elongation of the Uvula. — Accompanying pharyngitis, usually in its 
chronic form, an elongation of the uvula is at times met with in children. 



DISEASES OF THE NOSE, NASO-PHARYNX, AND PHARYNX. 817 

This condition may arise from a relaxed condition of the muscles of the 
soft palate and of the uvula, or may consist simply of a redundancy of the 
mucous membrane at the tip of the uvula. The general irritated condition 
of the uvula and the tickling sensation produced by its elongated tip touch- 
ing the base of the tongue cause a harassing cough, which by its persistence 
weakens the child, gives rise to loss of appetite, and interferes with its 
nutrition. 

Local applications of astringents, such as alum, are at times sufficient 
to restore the uvula to its normal condition, but the disease can be cured 
quickly by excising the end of the uvula with blunt-pointed scissors. 
The amputation of the entire uvula is to be avoided, as it has been known to 
weaken the muscular action of the soft palate. 

A papillomatous growth is sometimes found attached to the tip of the 
uvula or to its side, which causes the same symptoms as elongation of the 
uvula. The treatment is excision, after which it does not recur. 

Retropharyngeal Abscess. — Retropharyngeal abscess is a disease 
which occurs usually during the first year of life and is very rare after this 
time. The disease may be secondary to injuries of the pharynx, to abscess 
in the neck, and to disease of the cervical vertebrae, or it may be metastatic 
from septic processes such as occur in diphtheria. In a certain number of 
<3ases it is idiopathic so far as we know. 

Pathology. — The pathology of the disease consists in the formation 
of an abscess in the tissues of the posterior wall of the pharynx, and is 
more apt to be on one side of the pharynx than in the median line. 

Symptoms. — The symptoms, whether the disease is primary or second- 
ary, are very much the same. The first symptom is generally difficulty in 
swallowing, which may go on to entire inability to swallow. The infant is 
next noticed to breathe in a peculiar way. It holds its head back and its 
mouth open. The breathing may be described as snorting, and at times as 
almost stertorous, differing markedly from the whistling sound which is 
heard in obstruction of the larynx. On examining the throat the soft 
palate is seen to be pushed forward and to be somewhat ansemic. The 
posterior wall of the pharynx is bulging, usually unilaterally, is reddened, 
swollen, tense, and as the disease progresses is found to be fluctuating. In 
some cases the abscess burrows into the tissues of the neck and appears 
as a pear-shaped tumor behind the ear. I liave met with two cases of this 
variety where the pus could be reached easily by an external incision. 

Diagnosis. — The diagnosis must be made chiefly from peritonsillar 
abscess. This is, as a rule, not difficult unless the latter condition has 
proceeded so far that the pus by burrowing has invaded the walls of the 
pharynx. It is usually not difficult to determine the situation of the 
abscess by passing the finger directly through the mouth to the posterior 
wall of the pharynx. If there is pus in the tissues of the pharynx a 
sense of fluctuation will be obtained. The position of the child in cases 
of retropharyngeal abscess is also significant, and is not that which is 

52 



818 PEDIATRrCS. 

assumed in peritonsillar abscess. It holds its heaJ back, in order to allow 
a free passage for the air through the occluded pharynx into the larynx. 

The diagnosis must also be made from oedema of the glottis, but this 
is not, as a rule, difficult, for inspection shows that in the latter disease 
bulging, redness, swelling, and fluctuation of the posterior wall of the 
pharynx are not present. The characteristic position of the head, also, is 
not seen in oedema of the larynx. 

Prognosis. — The prognosis in the cases where the abscess is secondary 
varies according to the nature of the disease which causes it. Thus, it is 
an exceedingly dangerous complication in diphtheria, and is one of serious 
import in cervical spondylitis. In those cases of undetermined origin which 
are spoken of as idiopathic the prognosis is very good if the proper treat- 
ment is carried out at once. We must, however, consider the possibility 
of the abscess bursting suddenly, the child suffocating by inspiration of 
pus into the larynx. This has been known to occur where the disease has 
been left untreated. 

Treatment. — In the idiopathic cases the abscess should be opened at 
once. The method which I have found satisfactory in the cases which have 
come under my observation is to have an assistant hold the infant sitting 
upright in the lap, with a blanket tightly pinned around it so as to prevent 
it from moving its arms. Another assistant should hold the head. The 
mouth should then be opened, a guarded bistoury should be introduced 
into the pharynx and the abscess punctured. As soon as the opening has 
been made the bistoury should be removed quickly, and the infant's head 
should be immediately thrown forward and downward, so that the pus will 
be discharged from its mouth and not inspired into the larynx or swallowed. 
It is usually necessary after the operation to introduce the finger into the 
pharynx and to press the walls of the abscess, so as to empty any pus which 
may continue to collect there and also to keep the opening free. With this 
treatment, unless some complication should arise, the disease is usually 
cured in about a week. 

Some operators prefer having the child placed in what is known as 
Rose's position, on its back with the head hanging over the end of the table. 

Here is an infant (Case 402), seven months old, who has just been brought to the 
hospital. 

Without examining the throat, you can almost diagnosticate a case of retropharyngeal 
abscess by the character of the breathing, which is snorting and labored. You will notice 
the very characteristic appearance produced by the obstruction in the pharynx. You see 
that the head is held back and the mouth open ; that the infant's eyes are somewhat rolled 
upward, but that it is perfectly conscious. Its face is slights cyanotic. On depressing the 
lower jaw and tongue you see that the soft palate is pressed forward, that its blood-vessels 
are almost empty, and that it is very pale. On throwing a strong light from the mirror 
on the posterior wall of the pharynx you see on the left of the median line a swollen, con- 
gested, bulging condition of the mucous membrane. On touching the most prominent 
point of the swelling with the finger you get a sense of fluctuation . 

The infant is said to have been sick for two weeks with a cold in its head. Three days 
ago it began to breathe in this manner and to hold its head back rigidly and somewhat to 



DISEASES OF THE NOSE, XAS0-PHAEY2sX, AND PHARYNX. 819 

the left. It also began to hold its mouth open. It was able to nurse only a few seconds at 
a time, when it would let go of the nipple and refuse to take it again. It has been growing 
very weak from lack of nourishment and from the exhaustion arising from the difficulty 
with its breathing. 

Case 402. 




Ketropharyngeal abscess. Male, 7 months old. 

(Subsequent history.) An opening in the abscess was made by Dr. Burrell, and a large 
amount of pus was evacuated. An hour later the child began to choke, and it seemed as 
though tracheotomy would have to be performed, but pressure with the finger on the walls 
of the abscess from time to time, surrounding the infant with an atmosphere containing 
steam, and free stimulation, proved eventually to be all that was necessary for its recovery. 

I shall now report to you a case (Case 403) of retropharyngeal abscess which came 
under my observation some years ago. 

An infant thirteen months old, and always strong and healthy, had an attack of acute 
rhinitis for several days. The rhinitis apparently caused considerable swelling and occlu- 
sion of the nares, and the infant after four or five days began to hold its mouth open when 
breathing and to have difficulty in swallowing. This difficulty in deglutition increased, and 
it was then noticed that her head was held back. On examining the throat a tense fluctu- 
ating swelling was detected in the posterior wall of the pharynx very nearly in the median 
line. This swelling was incised by Dr. Hooper. A considerable amount of pus was evacu- 
ated, and the infant immediately began to breathe more easily and was able to swallow with- 
out difficulty. During the next twenty-four hours the abscess filled with pus a number of 
times, and the pus had to be emptied by pressure with the finger. The infant made a per- 
fect recovery, and has had no return of the disease. 

Cases such as this lead me to say a few words upon another method of 
drainage that I did not speak of when telling you about opening these 
abscesses that are found in the mouth. In the ordinary case, when the pus 
has come from the breaking down of glandular material in the posterior 
wall of the pharynx and already contains pyogenic bacteria, the dangers 
from reinfection from a wound in the mouth are not serious. But when 
the pus has come from a tuberculous focus in the cervical vertebrie and 
contains no other organisms than the bacilli of tuberculosis, and is more- 
over in direct communication with an active pathological process in the 
bone, the risks of a secondary septic infection are considerable. It is, 
therefore, the practice of many surgeons, despite the difficulties of the 
operation, to attempt to reach the abscess by a careful dissection from the 
outside of the neck, as it is far easier to keep the wound in that situation 
aseptic. If there is any sign of the abscess pointing externally, the outside 
operation should always be preferred. 



820 PEDIATRICS. 

I happen to have here another case of retropharyngeal abscess to show 
you, in which the condition is secondary to cervical spondylitis. 

Case 404. 




Retropharyngeal abscess secondary to cervical spondylitis. 

This child (Case 404) was being treated for cervical spondylitis by Dr. Bradford, when 
in addition to the drawing back of its head, which you see, it began to have increased 
difficulty in swallowing and to breathe with its mouth open. 

On examining the pharynx a bulging, tense, fluctuating abscess of moderate size was 
detected. 



DIPHTHERIA. 821 



LKCTURE XLII. 

DIPHTHERIA. 

DiPHTHEEiA is an acute, liighly infectious disease, due to the Klebs- 
Loeffler bacillus. It is primarily a local affection, the constitutional 
symptoms being due to the absorption of toxines. 

There is frequently a concurrent infection with pyogenic cocci. These 
organisms produce the secondary inflammations occurring in the disease, and 
also, by their toxines, give rise to additional constitutional symptoms. 

Etiology. — The Klebs-Loeffler bacillus, first described by Klebs and 
later more fully identified by Loeffler, is a small organism, 2.5 ,a to 3 m in 
length and 0.5 a to 0.8 ,a in thickness. Its most striking features morphologi- 
cally are its variation in form and the irregularity in its manner of staining. 
The ends of the organism are frequently clubbed, and in most cases, when it 
is stained, it shows a series of clear spaces with intensely stained particles. 
The form and size vary greatly under various circumstances. I have here 
a specimen (Fig. 102) from a blood-serum culture from the throat of a child 
in the diphtheria wards of the Boston City Hospital, which shows the 
morphology of this bacillus in its typical form. 



Fig. 102. 



^^ lip 



The bacillus of diphtlieria. 

It grows readily on a variety of culture media, and most readily on the 
modified blood-serum first introduced by Loeffler. It does not form spores. 
Welch and Abbot have shown that in fluids it may be killed by an exposure 
of ten minutes to a temperature of 58° C. (136.4° F.). Under favorable 
conditions it may remain alive for weeks, or even months, in fragments of 
dried membrane. The bacillus of diphtheria is best stained with Loeffler's 
alkaline methylen-blue solution. 

The pyogenic cocci most frequently found in the concurrent infections 
are the streptococcus pyogenes, alone or associated with the staphylococcus 



822 PEDIATRICS. 

pyogenes aureus, the former being the more important in its results. I 
have here some specimens (Figs. 103, 104) of these organisms, showing 
their morphology. 

Fig. 103. 



.,.», 



.••• 



• ^"^ 






streptococcus pyogenes. 







Fig. 104. 






•. 


• 


• ••- 

• ••• 


• • • 


• • 


•:•• 


• -..• .:• 






• • • • • - • 






•; 


•• 

• 







•J * m* •• •• • 

•*• *• • «•• • • « 

• • • • 

• ••• . •; 
••• 

•• • ••••• • *-• 



• •• 

staphylococcus pyogenes. 



You will notice that they both appear as dots, the streptococcus showing 
a tendency to arrange itself in chains, while the staphylococcus is irregularly 
bunched. 

There is no true diphtheria where the Klebs-Loeffler bacillus is not 
present, but its presence in a healthy throat does not constitute the disease 
diphtheria, although the individual may be the source of infection to others. 

The contagium of diphtheria is contained chiefly in the secretions of the 
throat and nose, and is communicated usually by direct or indirect contact, 
and, as a rule, not by the air. 

An unhealthy condition of the mouth, nose, or throat predisposes to the 



DIPHTHERIA. 823 

disease, as a lesion of the mucous membrane is necessary for its entrance. 
Sewer-gas and confined, impure air of any kind may act by weakening resist- 
ance to the bacillus, or, by producing a benign lesion in the throat, may 
offer a suitable nidus for the invasion of the bacillus. Although clinically 
it has been supposed that animals have primary diphtheria, this has not been 
conclusively proved bacteriologically. 

Although dipththeria may occur at any age, it is rarely met with in early 
infancy. It is most commonly seen from the second or third to the fifth 
or sixth year. It may occur more than once in the same individual. 

Pathology. — The most constant lesion in diphtheria is the presence of 
a pseudo- membrane in the upper air-passages, due to a combination of in- 
flammation and coagulation necrosis. 

It must be remembered, however, that the same anatomical condition 
may be caused by other bacteria and by irritants, and also that the process 
may be simply a catarrhal inflammation which does not go on to the forma- 
tion of a pseudo-membrane. It is evident, therefore, that there is no patho- 
logical condition characteristic of the action of the Klebs-Loeflfler bacillus. 

The adjacent lymph-nodes are apt to be swollen, and on microscopical 
examination they often show small foci of cell-necrosis : similar smaller 
necrotic foci may be found in other parts of the economy, such as the liver 
and the kidney, and are due to toxic absorption. There is also a general 
lymphatic hyperplasia, which is relatively greatest in the abdomen. The 
kidneys ordinarily show only parenchymatous degeneration, but in a few 
cases of concurrent infection they may present acute lesions. Hemorrhages 
into the serous membranes are often met with, and the organs in general 
show degenerative changes due to toxic absorption. Endocarditis is rarely 
seen. Catarrhal bronchitis and broncho-pneumonia frequently complicate 
diphtheria, and are caused by the inspiration of the pyogenic cocci. This 
was demonstrated by Prudden and Northrup in a very able paper which 
appeared in 1889. 

Incubation. — The time which elapses after exposure to the infection 
until the first symptoms develop may be only twenty-four hours or may be 
two or three days. This period, however, is a very indefinite one, since the 
interval between the access of bacteria to the mucous membrane and the 
time when they invade the membrane with their toxic eflects depends upon 
whether the tissues of the mucous membrane are vulnerable. Thus, it is 
probable that the bacillus diphtherise may exist in the mouth for an indefi- 
nite time without infecting the individual. 

Symptoms. — The prodromal symptoms of diphtheria are not especially 
characteristic. They may be acute in cliaracter or very miki and of a sub- 
acute variety. There are apt to be a sensation of chilliness, some heightening 
of the temperature, and more or less pain in the back and limbs. There is 
nothing, however, to distinguish this stage of the disease from many of the 
other aifections of children, such as a simple tonsillitis. The child may often 
complain of discomfort on swallowing, and on examining the throat the 



824 PEDIATRICS. 

fauces are found to be reddened. In a short time, however, more character- 
istic appearances will be found in the throat. A pseudo-membrane, white 
or grayish white, and commonly appearing on the tonsils first, develops, and 
on the second or third day usually extends to the soft palate and uvula. It 
may also appear in the pharynx. During this stage the throat becomes 
much swollen and the tonsils considerably enlarged, sometimes so as almost 
to meet in the median line. The membrane is usually firmly adherent to 
the mucous membrane, and as the case progresses it assumes a brownish- 
gray or yellowish-gray color. In addition to these lesions in the throat, the 
cervical glands are usually involved and become considerably swollen. The 
child, as a rule, shows grave constitutional symptoms and loses its appetite. 
The temperature in diphtheria is not characteristic, and is usually not espe- 
cially high, 38.3° or 38.8° C. (101° or 102° F.). The pulse is somewhat 
increased in rapidity, and is weak in proportion to the severity of the disease. 
In cases of a mild type the symptoms abate towards the end of the first 
week, the pseudo-membrane separates, leaving a raw surface behind it, the 
throat becomes less swollen, and the child feels much better. It is, how- 
ever, usually left much prostrated for a number of weeks, and even in these 
mild cases the toxic effects of the disease may show themselves in the form 
of a neuritis, with its accompanying paralysis, many weeks after the diph- 
theria itself has run its course. There may also even in mild cases be a 
slight discharge from the nares, owing to the involvement of the posterior 
nares, and a slight albuminuria. 

I have brought you into the diphtheria ward to-day to show you one of 
these mild cases of diphtheria. 

This boy (Case 405), five years old, has been sick for four days. His pulse is somewhat 
rapid, but of good strength. His respirations are slightly increased, but there is no retrac- 
tion. There is a slight discharge from the nose, and the cervical glands are somewhat 
enlarged. He takes his nourishment well, and is in a very fair condition. A culture made on 
Loeffler's blood-serum of a shred of membrane taken from the throat showed the presence of 
the Klebs-Loeffler bacillus and a large number of streptococci. The urine contains a small 
amount of albumin. 

I show you this case as especially illustrating the typical appearances of diphtheria in 
the throat, and in order that you may compare it with the typical appearances of the throat 
in follicular tonsillitis, which I showed you in a previous lecture (page 781). 

On examining this boy's throat (Plate VIII., facing page 781, Diphtheria) you will see 
small patches of grayish-white pseudo-membrane on the upper part of the left tonsil and 
spreading to the left arch of the soft palate. The membrane has also involved the right 
side of the uvula, the right arch of the soft palate, and the side of the right tonsil pointing 
towards the median line. There is also a patch on the right tonsil and one on the posterior 
wall of the pharynx. The tonsils are moderately enlarged and reddened, and the mucous 
membrane of the soft palate is also considerably reddened. 

When lesions of this character and having this distribution are seen in the throat you 
need have no doubt regarding the clinical diagnosis of diphtheria, and should at once have 
a bacteriological examination made. 

Variations in Type. — There are a number of variations which occur 
both in the severity of the disease and in the locality which is at first at- 
tacked or principally invaded. 



DIPHTHERIA. 825 

In some epidemics the Klebs-Loeffler bacillus seems to be far more 
virulent than in others, and in some individuals it produces much uiore 
serious symptoms than in others. The severity of the attack does not 
always depend upon the extent of the pseudo-membrane. In general the 
severity of the cases depends on three factors : (1) the virulence of the 
bacteria, (2) the local resistance, and (3) the general resistance. A number 
of what may be called atypical cases have been observed and carefully 
studied, especially by Koplik, where no pseudo-membrane was detected and 
where the morbid appearances in the throat were those of a simple catarrh 
or follicular tonsillitis. The virulent Klebs-Loeffler bacillus was detected 
in these cases, and other children infected by them presented the typical 
local lesions of diphtheria. 

In addition to these mild cases, the Klebs-Loeffler bacillus at times pro- 
duces a most malignant form of diphtheria. In these cases the child either 
shows a fairly mild form of the disease for a few days and then suddenly 
develops the severe form, or it may be attacked at once by very severe 
symptoms. It becomes dull ; the temperature is either slightly raised or 
may rise to 39.4° or 40° C. (103° or 104° F.), or higher; the pseudo- 
membrane spreads rapidly ; there may be a dusky efflorescence on the skin, 
simulating closely that which I have described in the malignant form of 
scarlet fever. There may also be a purpuric condition of the skin. The 
picture of these septic cases is very characteristic. There is a peculiar, 
sweetish odor of the breath. There are cyanosis and a marked waxy 
pallor. There are hemorrhages from the throat and nose, with a profuse 
muco-purulent discharge from the latter. The cervical glands are often 
enormously enlarged. The membrane has been known to extend in all 
directions, and sometimes even through the Eustachian tubes to the external 
ears. All degrees of severity are met with between the mild and malignant 
types of diphtheria. The membrane, instead of extending upward to the naso- 
pharynx, as occurs in the malignant cases just spoken of, may spread down- 
ward, attacking the epiglottis and the larynx, and cause serious obstruction. 

I have already told you that the pseudo-membrane most commonly 
appears first on the tonsils, thence spreading to the soft palate and to the 
uvula. The disease may, however, begin in the mucous membrane of any 
part of the mouth, nose, or throat. 

The Nose. — Diphtheria sometimes begins in the nose and spreads no 
farther. In these cases the disease is usually of a mild type, but it is 
infectious. These cases are especially liable to be overlooked, as the child 
for one or two days may show merely the symptoms of fever, mahiise, loss 
of appetite, and a discharge from the nose. On examining the nose care- 
fully, however, a pseudo- membrane will often be found. It is, therefore, 
very important in cases of this kind to have a bacteriological examination 
made, and to isolate the child until it is determined that the Klobs-Loeffler 
bacillus is not present. These cases are probably a prolific source of infec- 
tion to the community at large. 



826 PEDIATRICS. 

Where the naso-pharynx is affected, either primarily or secondarily 
through the nares or the pharynx, the constitutional symptoms are, as a 
rule, marked. This is in all probability accounted for by the great mass 
of absorbents in the naso-pharynx, where absorption takes place so easily 
that general septic poisoning quickly follows. Where the naso-pharynx is 
attacked by diphtheria, we usually meet with the most fatal results. 

The Larynx. — In some cases the Klebs- Loef&er bacillus produces its 
effects first on the mucous membrane of the larynx. In these cases the 
mucous membrane of the nose and pharynx may never show any evidence 
of a pseudo-membrane. The first symptom, as a rule, is a cough of a harsh, 
ringing nature. The temperature may or may not be raised. As the toxic 
absorption is slight, on account of the locality affected, the constitutional 
symptoms are correspondingly mild. The child's symptoms are those re- 
sulting from laryngeal obstruction. There is dyspnoea, with retraction of 
the intercostal and supraclavicular spaces, and later of the epigastrium and 
the lower chest. This is accompanied by an increasing cyanosis. The child 
is very restless, is forced to sit up in order to breathe, and, for the same 
reason, bends forward with its head back. In these extreme cases, unless 
relief is speedily afforded, the child soon dies of suffocation. In another 
set of cases a slower form of suffocation may result from the extension of 
the membrane downward to the bronchi, while in still another set death 
may result from a complicating broncho-pneumonia. 

A very prominent symptom in all forms of diphtheria may be cardiac 
weakness. In some cases the child may die suddenly without having pre- 
sented any previous symptoms, or death may have been preceded by attacks 
of semi-collapse. In other cases there may be a weak, fluttering, intermit- 
tent pulse throughout the disease, which persists during convalescence. 
Under these circumstances the child should always be considered to be in 
a critical condition, as death, sometimes sudden, is liable to occur. 

Complications and Sequels. — There are a number of complications 
which arise in diphtheria besides those of laryngeal stenosis and cardiac weak- 
ness. The most serious of these are broncho-pneumonia and acute nephritis. 

The form of pneumonia which complicates diphtheria is broncho-pneu- 
monia, which, I have already told you, is produced, not by the Klebs-Loef- 
fler bacillus, but by pyogenic cocci which have been inspired. Broncho- 
pneumonia is most frequent and most fatal in laryngeal cases which have 
been operated upon. 

Albuminuria is so commonly met with in both the mild and the severe 
cases of diphtheria that it should be considered as a part of the disease 
rather than as a complication ; as a rule, the greater the amount of albumi- 
nuria the more severe the case. Where acute nephritis complicates diphtheria, 
it is not usually accompanied by oedema or anasarca. 

Dysphagia may from the very beginning of the disease produce a pro- 
found impression upon the general nutrition. Otitis media occurs fre- 
quently. 



DIPHTHERIA. 827 

Among the more common sequelae are anemia and chronic catarrh. 

The most common and serious sequela of diphtheria is a peripheral 
neuritis, with its accompanying paralysis. This paralysis often does not 
appear until convalescence has been established, — perhaps in the third or 
fourth week from the time of the beginning of the attack. The paralysis 
may sometimes be merely of the muscles of the soft palate, in w^hich case 
the fluids taken by the mouth are regurgitated through the nose ; or it 
may have a general distribution, such as is seen in multiple neuritis. In 
the more severe cases of paralysis arising from this multiple neuritis, the 
lower extremities are affected and the knee-jerks are absent. The electrical 
reactions where the limbs are involved are the same as in peripheral neu- 
ritis from other causes. 

The prognosis in these cases of post-diphtheritic paralysis is good. 

Diagnosis. — Recognizing that the same pseudormembranous condition 
in the throat may occasionally be produced by the pyogenic cocci, as well 
as by the Klebs-Loeflfler bacillus, the clinical diagnosis of a typical case of 
diphtheria is not difficult. A provisional diagnosis of diphtheria should 
be based upon the appearance in the throat of a pseudo-membrane, which 
usually appears first on the tonsils and has a tendency to spread to the 
uvula, soft palate, and pharynx. When in addition to this a nasal dis- 
charge is present and the glands of the neck are much enlarged, you have 
a picture which is not shown by any other disease. The most common dif- 
ficulty met with clinically is in distinguishing between cases of acute follic- 
ular tonsillitis and diphtheria. 

As I have already stated, the local lesions produced by the Klebs- 
Loeffler bacillus may be merely a catarrhal inflammation or those of a 
follicular tonsillitis. All such conditions, therefore, should be looked upon 
with suspicion until the absence of the Klebs-Loeffler bacillus has been 
demonstrated bacteriologically. Although a membranous laryngitis may be 
due to other causes than the Klebs-Loeffler bacillus, yet this is so rare that 
every case of primary membranous laryngitis should be considered to be 
diphtheria until it has been proved that it is not. A decisive diagnosis of 
diphtheria in any case can, therefore, be made only by determining the 
presence of the Klebs-Loeffler bacillus. 

Prognosis. — Diphtheria is an extremely fatal disease, especially in the 
septic and obstructive cases. The mortality varies decidedly in diflerent 
epidemics and according to the age. Children under two years of age 
rarely recover. The rate of mortality seems to have lessened in cases where 
the antitoxin treatment has been thoroughly used. The symptoms which 
make the prognosis especially unfavorable are the extension of the mem- 
brane to the naso-pharynx or the larynx, extensive glandular enlargement, 
hemorrhage from the nose or into the skin, a high grade of albuminuria, 
broncho-pneumonia, and a weak heart. Morse, in an extensive study of 
the leucocytosis of diphtlieria, has sho^Aii that it is of no })rognostic value. 
The cases of neuritis invariably recover. The prognosis in all cases is 



828 PEDIATRICS. 

uncertain, and should be given with caution, as death from heart-failure is 
liable to occur at any stage of the disease. 

A child who has had diphtheria is liable to suifer from the deleterious 
effects for months or even years. 

Prophylaxis. — All patients with diphtheria should be isolated until 
the Klebs-Loeffler bacillus has disappeared from the nose and throat. The 
time when this occurs varies from a few days to a number of weeks. 

In order further to protect the community, all cases of sore throat should 
be examined, and if the Klebs-Loeffler bacillus is found the individual 
should be isolated. It is especially necessary to carry out this precaution in 
schools, where the conditions are so favorable for the spread of the disease. 

The throats and noses of all persons exposed to diphtheria or caring 
for diphtheritic patients should be repeatedly examined for the Klebs- 
Loeffler bacillus, and if this is found they should be given immunizing 
doses of antitoxin, the amount and frequency of the doses to be modified as 
our knowledge increases. If in the future it is proved that the antitoxin 
may produce serious effects in certain individuals, these views must be 
modified to correspond to this additional knowledge. If the Klebs-Loeffler 
bacillus is found in these individuals, they should be isolated so long as the 
bacillus is present. To shorten the period of isolation, mild antiseptic 
gargles or douches should be employed. Whether the isolation of healthy 
persons who have the Klebs-Loeffler bacillus in their throat or nose is ad- 
visable or not is still a mooted question. Much confusion has arisen because 
of the so-called pseudo-diphtheritic bacillus. The weight of evidence at 
present, however, goes to show that it does not exist, and that the bacteria 
described are merely Klebs-Loeffler bacilli of diminished virulence. At any 
rate, even if the pseudo-diphtheritic bacillus exists, it is so rare that it may 
be safely excluded in clinical work. The fact that the Klebs-Loeffler bacilli 
found in healthy throats may not be virulent is not an argument against 
isolation, because it is well known that a non-virulent form may become 
virulent when transferred to a different soil. Examinations of many healthy 
throats have shown that the Klebs-Loeffler bacillus is a very rare inhabitant 
of the normal throat, and that when it is present diphtheria often develops 
later. Theoretically, therefore, although it may be impossible or inad- 
visable practically, it would seem Avise to consider the Klebs-Loeffler bacil- 
lus virulent until it has been proved to be non-virulent, and to consider its 
presence a source of danger to the community until it is proved not to be. 

In addition to what I have already said, I must impress upon you the 
importance of keeping the teeth in good order as a prophylactic measure, as 
well as keeping the mucous membrane of the nose and throat in a normal 
condition. 

Treatment. — The treatment of diphtheria consists (1) in attending to 
the hygienic conditions ; (2) in the administration of remedies, either by the 
skin or by the mouth, to combat the toxine which produces the constitutional 
symptoms ; (3) in local applications to the nose, throat, or larynx, and in 



DIPHTHERIA. 829 

measures directed to the general condition ; (4) in operative measures to 
relieve obstruction in the larynx. 

One of the most important parts of the treatment of diphtheria is the 
management of the room in which the patient is kept during the progress 
of the disease. It is well known that pathogenic organisms, such as the 
Klebs-Loeflfler bacillus, do not thrive where they are exposed to sunlight 
and fresh air. The room should be thoroughly ventilated, and fresh pure 
air should be allowed to come continuously into it. It should also be one 
which has a sunny exposure. 

In any treatment directed to the cure of diphtheria in young children 
we must remember that the disease is so exhausting that the treatment, as 
a rule, should be forced upon the child as little as possible. Any physical 
exhaustion produced by the treatment is to be considered serious in young 
children. 

It is necessary perhaps to call your attention to the fact that much 
care should be taken both by the physician and by the nurse not to become 
infected themselves by the secretions from the mouth and nose of the patient. 
These secretions are especially dangerous if they happen to get into the eyes. 
It is probable that with extreme care there is not much danger of the 
spread of diphtheria in a household, as we know its tendency is not to dis- 
seminate itself in the surrounding atmosphere. Hence it is likely that with 
proper precautions it can be limited to the room in which the child is sick, 
and that if it extends beyond this room it has been carried directly by the 
hands or clothing of the nurse or the physician. 

According to the knowledge of the present time, the most promising of 
all these forms of treatment is the second. This treatment is essentially 
comprised under what is called serum therapeutics. By serum therapeutics 
is meant the treatment of disease by injecting into the patient the serum of 
an animal which has been rendered immune to the especial disease, which is 
being treated, by means of inoculation with the toxine of that disease. The 
serum taken from the animals which have been rendered immune against 
diphtheria is called antitoxin serum. The serum is injected under the skin, 
usually in the thigli, and the place selected should always be one on Avhich 
pressure is not exerted when lying in bed. The dose should be from 500 to 
1000 antitoxin units, or 10 to 20 c.c. (J to f ounce) of the 1 to 50,000 
serum, according to the age of the child and the severity of the disease. 

The beneficial results of antitoxin are decidedly greater if the injection 
is made in an early stage of the disease than if made in the later, although 
even when administered late in the disease it sometimes produces wonder- 
fully curative effects. When given early, within the first forty-eiglit liours 
of the disease, even where the membrane is spreading rapidly and infiani- 
mation of the glands with general systemic poisoning has taken place, one 
injection will often arrest the disease. Where im]^rovement does not take 
place within twenty-four hours, a second dose, and, if necessary, a hirger 
one, should be used. The sign by which we know that the antitoxin serum 



830 PEDIATRICS. 

is beneficial is the improvement in the general condition of the patient. 
The effect of the antitoxin on the pseudo-membrane is characteristic. The 
pseudo-membrane ceases to spread, frequently whitens, shrinks, shows 
a line of demarcation, and usually within the next three or four days 
becomes detached from the mucous membrane. The temperature usually 
rises after the injection, but in a few days falls to the normal by lysis. In 
the more severe cases a single injection of the serum does not work so 
quickly. In these cases the temperature falls usually by lysis after the 
second or third dose. The pulse becomes normal two or three days after 
the temperature has fallen. The irregularities of the pulse are not so fre- 
quent in diphtheria since the antitoxin treatment has been employed. The 
effect of antitoxin on the albuminuria is still sub judiee, but it probably 
does not increase the likelihood of its occurrence. When there is a concur- 
rent infection the antitoxin serum is less effective, since it does not coun- 
teract the toxic absorption due to other bacteria than the Klebs-Loeffler 
bacillus. It is not safe to assume, however, that there is a concurrent infec- 
tion because other bacteria are found in the throat. 

When the larynx is involved, with accompanying stenosis, the antitoxin 
serum is found to be very valuable, and has reduced the number of operative 
cases. 

In connection with the antitoxin treatment no specific drugs given inter- 
nally by the mouth are indicated. Stimulants should always be given freely 
in diphtheria. Of course, symptomatic treatment of any kind is not contra- 
indicated. 

The antitoxin has been found to have but little effect on the length of 
time during which the bacteria remain in the throat after the disappearance 
of the membrane. 

Too few cases have as yet been observed to estimate the relative fre- 
quency of the occurrence of neuritis since the treatment by antitoxin has 
been introduced. Various skin and joint complications, accompanied by 
fever, occur in a certain proportion of the cases in which antitoxin is used. 
Albuminuria has been attributed to its use ; but, as already stated, this 
question must still be considered as sub judioe. Antitoxin is also said to cause 
serious and even fatal results in some cases. How much danger there may 
be in its use cannot as yet be estimated, but must be left to the future to 
decide. Careful clinical observations and autopsies on fatal cases in which 
it has been used can alone enlighten us. 

The local treatment of diphtheria consists in thoroughly cleansing the 
mouth and nose with warm, non-irritating solutions, such as normal salt 
solution, or boracic acid four per cent. All strong and irritating applica- 
tions to the throat in diphtheria are harmful. 

The technique of the local applications to the throat and nose is impor- 
tant. The most simple, efficacious, and safe, and that which produces the 
least discomfort, is by irrigation. The same method — namely, by means of 
a fountain syringe — should be employed for either the throat or the nose, 



DIPHTHERIA. 



831 



except that in the former a larger hard- rubber nozzle should be used than 
for the nose, and one which is sufficiently long to pass over the base of the 
tongue, 

Here is an illustration (Fig. 105) of the method of irrigation as em- 
ployed in the Boston City Hospital and at the Willard-Parker Hospital in 
New York. 

Fig. 105. 




Irrigation of nose in diphtheria. 



The child should lie on its side, and the water should be made to pass up 
one nostril and down the other until the stream runs clear. In some cases 
the child prefers to sit up while the irrigation is done. Ordinarily, the 
irrigation should be used once in two or three hours, perhaps with longer 
intervals at night. If the child resists this treatment, it may be advisable, 
in order to save its strength, to omit it for a time. This rule applies to all 
forms of local treatment. 

Considerable suffering is at times occasioned by the enlargement of the 
cervical glands. Some patients prefer the application of ice poultices, others 
of hot flaxseed poultices. Either may be used if they produce the desired 
effect of reducing the discomfort. 

Nutritive enemata made of peptonized milk, with stimulants, may, when 
retained, be an important adjunct to the treatment. Enemata, however, are 
often not retained. Digitalis may be used in cases where heart-failure is 
anticipated. In cases where there is a faucial paralysis the child may often, 
with success, be fed through the nostril by means of a soft-rubber catheter 
passed into the oesophagus ; this method may also be used after intubation 
where there is unusual difficulty in swallowing. 

Where measures are found to be necessary to reduce obstruction in oases 
of stenosis of the larynx, the child should be placed in an atmosphere of 
steam, and if this does not relieve the stenosis the sublimation of calomel 



832 PEDIATRICS. 

should be employed. In either case, however, we must remember that the 
child should not be kept in this atmosphere continuously, and should be 
watched carefully to see if it is speedily relieved of the stenosis ; for if it 
is not, the continuous inhalation of steam in the comparatively small area 
of breathing space which exists in the tent that is used for this purpose 
may of itself be detrimental to the child's recovery, from lack of sufficient 
oxygen. When tracheotomy has been performed an atmosphere of steam 
is especially valuable. 

The tent, as described by Dr. Northrup, who has used it so extensively 
in the Willard-Parker Hospital in New York, contains about fifty cubic 
feet of air. To extemporize a tent, a sheet is thrown over supports above 
the crib and allowed to fall over the four sides of the crib. The main 
point is to have a fairly large and tight enclosure. The apparatus for fur- 
nishing the steam or sublimation must be free from the danger of upsetting 
and of setting the tent on fire. For sublimation, a deep vessel, such as 
a wash-bowl, should have an alcohol lamp placed in it, and over its top a 
tin strip. Over the space where the flame of the alcohol lamp touches the 
under side of the strip a little, compact pile of calomel, sufficient for a single 
sublimation, is placed. Eight or ten minutes are required to volatilize the 
calomel, and the tent should be kept closed about fifteen minutes. A safe 
and satisfactory method is to volatilize in an ordinary crib-tent 0.3 gramme 
(5 grains) of calomel every two hours for two days and nights, and then 
prolong the intervals to three hours on the third day, four hours on the 
fourth day, and later three times a day, according to indications (O'Dwyer). 
It has been Dr. Morse's experience that 0.6 gramme (10 grains) every half- 
hour for four or five times will sometimes produce good results where the 
smaller doses have failed. 

The nurse may easily become salivated from inhaling the calomel fumes, 
and should be cautioned in regard to this. The child should not be exposed 
to a sudden change of temperature when the sublimation is over. The room 
should be thoroughly aired after opening the tent, and it is well to remove 
the child to another room while this is being done. Young children do not, 
as a rule, suffer from ptyalism following this sublimation. Older children, 
after a number of days' treatment, may show a mild stomatitis, and some- 
times diarrhoea. Chemically pure calomel is essential, as the impure drug 
may cause conjunctival irritation. If the fumigation has to be very pro- 
longed, anaemia may be caused. This should be combated by iron, and if 
there is prostration, a little whiskey should be given before the sublimation. 

The sublimation of calomel is indicated where the symptoms of laryngeal 
obstruction are urgent, and may be used alone or in conjunction wath steam. 

Where the antitoxin does not relieve the symptoms of stenosis, and 
yrhere the progressive dyspnoea is not quickly controlled by steam or calomel 
sublimation, it is well not to delay operative interference. The operative 
means of relieving stenosis of the larynx is by intubation or by tracheotomy. 
The indications in either case are, according to Xorthrup, a progressive, 



DIPHTHERIA. 833 

unremitting dyspnoea, when the labored breathing begins to produce sen- 
sible exhaustion, and when the supraclavicular and lateral thoracic retrac- 
tion is marked. It would not be within my province to speak of the 
relative advantages of intubation and tracheotomy. Each operation has its 
strong exponents, and so much has been said in favor of both operations 
that the question as to which is best must be decided by the individual 
surgeon in the especial case. It is probable that the antitoxin treatment 
will increase the field for intubation in operative cases. 

In the treatment of post-diphtheritic paralysis strychnine is the most 
valuable drug. Electricity, especially faradism, is also indicated. 

The subsequent ansemia, which I have already referred to, should be 
treated in the usual way. 



53 



DIVISION XIII. 

DISEASES OF THE (ESOPHAGUS, STOMACH, AND 

INTESTINE. 



LECTURE XLIII. 

INTRODUCTION. 

Befoke speaking in detail of the diseases of the stomach and intestine, 
a few general remarks are necessary to explain how limited is our knowledge 
of these diseases. Those diseases, however, which affect the oesophagus can 
easily be classified on a pathological basis, and are so few in number that 
they can be included in these general remarks. 

CBSOPHAGUS. — The diseases of the oesophagus are rare in infancy 
and early childhood. There may be congenital malformations, such as nar- 
rowing or dilatation. The swallowing of hot or corrosive liquids may cause 
obstruction, which is occasioned by a cicatricial stricture. (Esophageal 
stricture may also occur as a result of congenital syphilis. Pressure outside 
of the oesophagus may cause obstruction. These strictures, especially those 
of cicatricial origin, are accompanied by a great deal of muscular spasm, 
which at times is constant, and again relaxes. Thus, the child will swallow 
with comparative freedom at intervals, while at other times the obstruction 
appears to be complete. In addition to the inability to swallow, and the 
consequent regurgitation of the food, the secretion of saliva and mucus is 
often very profuse, and causes symptoms of distress and choking. 

The diagnosis and treatment of these cases are effected chiefly by means 
of bougies ; but, as much harm may come from these instruments, and as 
especial surgical knowledge is required to use them and to decide whether 
oesophagotomy should be performed, I shall not dwell on this class of cases. 

An inflammatory condition of the oesophagus is said to occur in young 
infants, and is spoken of as oesophagitis. It is rare. The symptoms, as 
described by Billard, are unwillingness to nurse, crying, immediate regurgi- 
tation after beginning to suck, and often some tenderness about the neck on 
pressure. The prognosis is bad. 

It is quite common for children to swallow various foreign bodies, such 
834 



DISEASES OF THE OESOPHAGUS. 835 

as buttons and pins. These bodies may either be caught in the back of the 
throat or lodged in the oesophagus, instead of passing through to the stomach. 
A careful examination of the throat with the finger should first be made, 
and if the foreign body is not detected in the throat the oesophagus should 
be explored carefully with a bougie, and the foreign body is then usually 
pushed through into the stomach, unless it is thought wiser to remove it 
with the bristle probang. The diet for the following twenty-four to forty- 
eight hours, or until the body has been passed through the intestine, should 
be such as will give sufficient consistency to the faeces to protect the intes- 
tine from injury while the body is being passed over its surface. Various 

Fig. 106. 



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"i/. 



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y 

Congenital dilatation of oesophagus, female, 10 weeks old (3^ natural size). 

preparations of the cereals are useful for this purpose. If necessary, a dose 
of oil can be given, but, as a rule, active treatment is contra-indicated. 

I have here a specimen of the oesophagus and stomach of an infiint 
(Case 406) ten weeks old which shows the condition of congenital dilatation 
of the oesophagus (Fig. 106). 



836 PEDIATRICS. 

The infant was healthy at birth, and its mother had a plentiful supply 
of breast-miik. During the first two or three weeks of its life nothing 
abnormal was noticed about it, except that it vomited occasionally. When 
it was four weeks old it began to regurgitate, vomited the milk frequently, 
and lost in weight. The fsecal discharges showed that the milk which 
reached the stomach and intestine was fairly digested, but the discharges 
were infrequent and small in number. It was weaned when it was nine 
weeks old, and small amounts of milk, carefully modified in various ways, 
were given to it. No improvement in the symptoms followed this treat- 
ment, and although at times a small quantity of milk would be retained, 
yet, as a rule, after a few minutes the milk was regurgitated. The infant 
had no other symptoms, but rapidly lost in weight, and finally died of 
exhaustion. 

The post-mortem examination was made by Dr. Whitney, and the only 
pathological conditions found were, as you see, in the oesophagus. The 
last two inches of the oesophagus were dilated into a more or less cylindrical 
swelling, with marked thinning of the walls and atrophy of the mucous 
coat. A dilatation had been formed in which evidence of a small area 
about to perforate into the mediastinum was found. The entire stomach, 
as well as its cardiac and pyloric orifices, was markedly contracted, appar- 
ently from lack of use. 

STOMACH AND INTESTINE.— Our knowledge of the diseases of 
the stomach and intestine is exceedingly limited, and is especially so where 
infants and young children are concerned. The classification of these dis- 
eases on a pathological basis has been proved to be inadequate, and in like 
manner a classification on the basis of symptoms is insufficient. Bacterio- 
logical investigations, however, have advanced our knowledge to such an 
extent that we may hope in the future to be able to classify these diseases 
on an etiological basis. The terms dyspepsia, dysentery, diphtheritic, 
croupous, and others have become almost unmeaning, and should be replaced 
by terms more closely connected with the etiology of the disease. 

Accordingly, the American Pediatric Society requested Dr. Holt and 
myself to prepare a nomenclature which would correspond more nearly to 
our present knowledge of this exceedingly difficult subject. I wish es- 
pecially to emphasize the value of Dr. Holt's work, which has aided me 
so much in my own studies on this subject. The classification finally 
adopted by the Society was one which especially relates to infants and 
young children, and you must remember that in what I am about to say 
concerning this important class of diseases I am dealing especially with this 
early period of life. The diseases of the gastro-enteric tract as they occur 
in older children resemble so closely those of adults that they need not 
occupy a prominent place in lectures on children, especially as the pathology 
and symptoms of this later period of life differ very materially from those 
of the earlier periods. These differences are still more strongly marked 
from the fact that children succumb much more readily to the early stages 



DISEASES OF THE STOMACH AXD IXTESTIXE. 837 

of a disease than do adults, and may die before the later and more charac- 
teristic lesions and symptoms of the disease have developed. There are 
certain known facts resulting from the anatomical and physiological peculi- 
arities existing in infancy which play a significant part in all these diseases. 
It is well, therefore, first to explain the general principles which influence 
the symptoms and prognosis of these diseases before attempting to describe 
each disease separately. In many cases we can arrive at only approximate 
conclusions as to the actual lesion which exists and the prognosis which 
should be given. A practical clinical diagnosis should be made according 
to the region where the stress of the lesion exists, rather than to the patho- 
logical lesions which are present. 

General Etiology. — In the present state of our knowledge it is not 
practicable to discuss in detail the various supposed causes of gastro-enteric 
disturbances. AVe can suppose that these disturbances may be due to ner- 
vous conditions which may act alone or may render the tissues vulnerable 
to bacteria. Some of these diseases are caused by specific organisms, while 
others are due to a number of organisms. These bacteria act either of 
themselves or through their products. 

In a general way, these diseases can be classified as functional and 
organic. The organic class may be divided into inflammatory and non- 
inflammatory diseases, although the boundary-line between these two con- 
ditions is at times very doubtful. A prominent and important peculiarity 
of these diseases as they occur in infancy is, as would naturally be expected 
at this early period of development, a variety of symptoms which are pro- 
duced by reflex causes. By the term reflex we mean peripheral irritation 
with a resulting action. By functional we mean a disturbance of the fimction 
of the organ without a known lesion. By organic we mean a known lesion. 

In addition to these cases are others which, as yet imperfectly under- 
stood, seem to be produced by certain morbid products eliminated from the 
blood by the gastro-enteric tract, as, for example, urea. This etiological 
factor can be spoken of under the term eliminative. 

General Pathology. — The general pathological anatomy of the 
gastro-enteric tract of infancy and early childhood is essentially that of the 
ileum and colon. In those cases in which the more severe lesions are 
present the stress of the lesion is usually in the lower ileum and the colon, 
and very frequently in the colon only. For this reason the terms ileo- 
colitis and colitis seem more descriptive than ileo-enteritis and enteritis. 
The pseudo-membrane in ileo-colitis is often extensive, but sloughing and 
perforation are exceedingly rare in young children. It is at present believed 
that not all ulcers of the prastro-enteric tract are necessarily inflammatory. 
The great number of lymph-nodules and the abundance of the lymphatic 
plexuses are the principal anatomical conditions whicli influence the ]iathol- 
ogy of the enteric tract in early life. 

General Bacteriology. — The knowledge of tlie diflorent bacteria 
which occur in the gastro-enteric tract, and of the connection which they 



838 PEDIATRICS. 

have with the different diseases, is at present, with few exceptions, uncertain 
and unreliable. There is little doubt that the bacteria may find their way, 
by means of the stomach, to the intestine, and that the acid secretion of the 
stomach which they meet in their way through it is not sufficient to prevent 
their arriving alive in the intestine. We know that these bacteria play such 
an important role in their etiological relations to the various diseases that 
full weight must be given to their presence when we are treating the disease. 
It would seem that the bacteria which are commonly found in the intestine 
when it is in a normal condition do not cause any abnormal conditions ; but 
when the intestine has become irritated, from mechanical or thermic causes, 
the bacteria are able to penetrate its mucous membrane, become noxious, 
and produce abnormal symptoms, often of a serious nature. 

General Symptomatology. — Vomiting as a symptom is often very 
misleading in early life, so far as the differential diagnosis between the 
stomach and the intestine is concerned, as it frequently occurs from disturb- 
ance in any part of the gastro-enteric tract, and should not be considered 
as indicative of any one disease. Serious symptoms during life are often 
proved at the autopsy to have been produced by no pathological lesion, 
while grave lesions may be found at the autopsy where the intestinal symp- 
toms during life were very mild. 

Marked diarrhoea may exist during life and no lesions be present at the 
autopsy. Serious lesions may exist, and yet no blood appear in the dejec- 
tions. Blood may appear in the dejections, and yet no serious lesion exist, 
the hemorrhage being only temporary, and comparable to epistaxis. 

General Diagnosis. — The observation of the temperature is very 
important for the diagnosis of these diseases. As a rule, an elevated tem- 
perature of short duration points towards functional and toxic disturbances, 
while an elevated temperature long continued points towards inflammatory 
lesions. 

Intestinal discharges are often very misleading for diagnosis. 

Having considered and accepted these general principles relating to dis- 
eases of the gastro-enteric tract in infancy, the American Pediatric Society 
adopted the following classification (Table 109), as presented to them by 
their committee. This classification must be understood to be merely pro- 
visional, and is for the purpose of aiding those who are interested in this 
subject to work with uniformity. 

At the same time it is believed that it is a great advance upon the 
unmeaning and misleading nomenclature now current. 

On examining this table (Table 109) you will see that whenever the 
etiology has been definitely determined it is made to designate the disease, 
but the true etiology is still unknown in so many cases that other terms 
have of necessity been used, the names simply representing the extent of the 
knowledge we have of the especial disease. 

The diseases of the gastro-enteric tract may, on this basis, be divided 
into diseases of the stomach (gastric), diseases of the intestine (enteric), and 



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TABLE 109. 






Malformations 
Malpositions. 




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CENTRAL, 
many causes, 


AnUe .... 


[ ImUgeslion. 
. IiiaKjcriion. 


eular 
I fright, e 


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iWoii-IaJlamma- 


\ Mechnnical, dilatation, etc. 
1 New Orowths. 













Pseudo-Memliranosa. 

Such as, according toWollstein in Archives oj PedicUrics fm- July, 
1892, is met with in exhausting diseases, atelectasis, diphV 
tuberculosis, etc. 



xhausting diseases, atelectasis, diphtheria, 



Nei-voHS (exagger- 
ated peristalsis 
causing diar- 



Nervous (exagger- 
ated peristalsis 
causing diar- 



CENTRAL. 
Heat, cold, fright, ■ 



REFLEX. 
Foreign bodies, food, or otherwii 



Indigeslioa . 
Inconiivence. 
Consdpalion . 



normal or hyper£emi( 



Especially ol' duodenu 



tine may be affected, and the condition of the i 



CENTRAL. I 

Heat, cold, fright, etc. | 

Both small and large intestine may be affected, 
normal or hypersemic. 
Especially of duodenum : usually much 



REFLEX. 
Foreign bodies, food, o 
he condition of the mu 

, in discharges, prominent abdo: 



GASTRO- 
ENTERIC 
TRACT. 



Non-Inflamma- 



Cholera Injanlnm. 
Cholera Asiaticn . 



Apparently a vice of absorption. 

Dilatation of Colon. 

Volvulus. 

Intuftsusception. 

Fissures. 
Prolapse. 
Polypi. 
Hemorrhoids. 

FistuLx. 

Our present knowledge of fermentation and decomposition includes 

ACID FERMENTATION AND ALBUMINOUS DECOMPOSITION. 

In both these forms it is probable that it is the small intestine which is most affected. The 
condition of the mucous membrane may be normal, or there may be desquamative catarrh. Tliis 
process may go no further, or may be followed by inflammatory changes. 
Stomach (vomiting). 
Small and large intestine affected. 

Condition of mucous membrane is desquamative catarrh and sometimes hypericmia. 
Comma bacillus. 



CATARRHALIS. ULCERATIVA FOLLICULARIS. 

Ileum and colon chiefly affected. Ileum and colon chiefly affected. 

Stomach apt to be involved. 
This form includes the non-uleer- 
Ltive form of follicular inflamma- 



Tn both these forms the lesions are so varied that they probably arise 
from a number of organisms. Their pathology must for the present be 
collectively all forms which cannot be classed under the pseudo-mem- 
branous and amcebic. They may occur as acute primary diseases, but 
are usually secondary to the ferraental diarriiceas, and sometimes to the 
general infectious diseases, especially measles. 



PSEUDO-MEMBRANOSA. 
(Sporadica or Epidemica.) 
Ileum and colon chiefly affected. 

The lesions are probably due to a number of organisms. 
Tbe pathology is characterized by the presence of a membrane on the 
surface aud extending into the mucous membrane, due to a combination 
of fibrinous exudation and necrosis. That is, there is a definite patliology. 
The disease may be 

Primai-y, the usual epidemic or sporadic dysentery, or 
rtain infectious diseases, such as measles. 



UeO'CoUtis or Colitis 



Colon chiefly affected. 

A definite etiology. 

Amoiba coll. 

There are definite anatomical 1 



TYPHOIDAL. 



Ileum and colon chiefly affected. 
A definite etiology and pathology. 
Typhoid baciUus. 



Fig. 107. 




Colon showing presence of bismuth which had been given by the mouth. 



DISEASES OF THE STOMACH AND INTESTINE. 839 

the disturbances which arise from animal parasites. The diseases are then 
divided into those which arise from developmental, those which arise from 
functional, and those which arise from organic causes. The organic diseases 
are subdivided into non-inflammatory and inflammatory, and the functional 
and organic diseases into acute and chronic. 

General Treatment. — In the treatment of these diseases we should 
endeavor to carry out four general rules : (1) to combat the serious condi- 
tions already referred to ; (2) to dislodge the bacteria as quickly as possible, 
perhaps by laxatives and irrigation ; (3) not to introduce into the gastro- 
enteric tract for a certain period food which may prove a favorable culture 
ground for the bacteria, since it has been shown that where the food is 
sterile when it enters the gastro-enteric tract it is quite eflPective in reducing 
the number of bacteria in the intestine ; (4) to introduce such drugs into 
the gastro-enteric tract as may, by their anti-fermentative and germicidal 
powers, diminish the action of or destroy the bacteria. This last rule is, 
however, very difficult to carry out, and, with our present knowledge 
of drugs and their administration, practically impossible. It is true 
that we know that subnitrate of bismuth is an anti-ferment, and that it 
reaches the part of the enteric tract which we know to be most affected in 
enteric disturbances characterized by fermentation. In proof of this I 
need simply refer you to this intestine (Fig. 107) of an infant, given to me 
by Dr. Holt, to illustrate this point, where bismuth had been given, and 
where at the autopsy the bismuth was found thickly coating the mucous 
membrane of the small intestine, and also appearing in the large intestine. 
It is, however, questionable whether in any case the attempt to kill the 
bacteria by the internal administration of drugs has been successful. 
Preparatious, such as salol, which are known to be broken up into their 
carbolic acid components on reaching the intestine, cannot with safety be 
given to the infant in doses large enough to kill the bacteria, for in such 
doses there may be serious results from poisoning. We can, however, 
possibly, by means of these germicidal drugs, produce a condition in the 
intestine which, though not conducive to the death of the bacteria, may yet 
be so unfavorable for their growth as to aid our treatment when we are en- 
deavoring to dislodge them. Nothing definite has, however, as yet resulted 
from using drugs for this purpose, and, so far as I can judge, the danger 
of treating infants or young children in this way is greater than the good 
that may result from it. 



840 PEDIATRICS. 



DISEASES OF THE STOMACH. 

From what I told you in the last lecture you will understand how diffi- 
cult it is to make a differential diagnosis between gastric disease and gastro- 
enteric disturbance. The only symptom which definitely shows the stomach 
to be involved, whether from reflex, functional, or organic conditions, is 
vomiting, and, as we know that in many cases vomiting is caused primarily 
by disturbance of the intestine, we really have no symptom which represents 
gastric disease alone. The difficulty of locating disease in the stomach is 
rendered still greater by the fact that serious organic lesions may exist in 
the stomach without any symptoms whatever, whether of vomiting, pain, 
or tenderness. We must, therefore, be exceedingly cautious in making a 
diagnosis of diseases of the stomach. 

Diseases of the stomach may arise from developmental, functional, or 
organic causes. 

DEVELOPMENTAL. — Under developmental affections of the stomach 
are included malformations and malpositions. A malformation of the stom- 
ach may be represented by a narrowing of either the cardiac or the pyloric 
orifice, or by constrictions in various parts of the ventral cavity, which are 
known as hour-glass contractions. A malposition of the stomach may be 
met with in various places, one of which is in the thoracic cavity. These 
malpositions, however, are exceedingly rare, and of pathological rather than 
of clinical interest, as the diagnosis can scarcely be made during life. 

FUNCTIONAL. — The functional diseases of the stomach play a great 
role in infants and in young children. They may be of an acute or a chronic 
variety, or may be what I have spoken of as eliminative. The latter class, 
in which certain morbid and irritating substances are supposed to enter the 
stomach as though it were an excretory organ, may in the future explain 
many of the rather obscure gastric symptoms which arise in early life, but 
at present our knowledge concerning this class of cases is so slight and 
indefinite that they need merely be alluded to. Acute functional gastric 
symptoms may be produced by a number of causes, but in general they 
are to be understood as arising from a 7iervous condition represented by 
vomiting or by a disturbance of the function of digestion, which had best 
be spoken of, until more is known of the subject, as simple indigestion. 

Nervous (Vomiting). — Vomiting may arise from gastric or from 
intestinal irritation in many diseases, such as tubercular meningitis, from 
heat, cold, fright, and from other causes. Direct irritation, from foreign 
bodies, food, or otherwise, may produce a reflex form of vomiting. In 
these cases the cause, if possible, should be removed, and the stomach given 



DISEASES OF THE STOMACH. 841 

a complete rest until the nervous disturbance has subsided. As a rule, 
no internal remedies are indicated in these cases, except an emetic where 
the vomiting arises from the reflex causes just described, or, if necessary, 
lavage. 

There is one form of vomiting, however, which is of such importance 
that it must be spoken of as a disease by itself. There is no name which 
can be given to it except that of persistent vomiting, as no single definite 
cause nor any pathological lesion has ever been proved to produce it. It has 
not even been shown that it is a primary disturbance of the stomach. In 
fact, in many cases it is possible that the source of irritation is entirely out- 
side of the stomach, and perhaps connected with the great sympathetic 
ganglia, such as the solar plexus. 

'^ Etiology. — The inciting cause of the vomiting in most cases is obscure, 
but is evidently very varied. It does not seem to be produced especially by 
errors of diet, but, on the contrary, occurs in children whose diet has been 
most carefully regulated. Undue exposure to cold, fright, and excitement 
all appear to me to have sometimes an etiological influence on the disease. 
This form of vomiting may occur at any age. I have met with cases in 
young infants and throughout the whole period of childhood. The attacks 
may occur not only in delicate, nervous children, but also in those who are 
quite vigorous. 

Symptoms. — The attack is very apt to come on suddenly, the child 
being previously in good health and not having shown any digestive disturb- 
ance. The period over which the disease extends and the intervals of the 
vomiting during the attack vary considerably, but in those cases which have 
come under my notice they are somewhat as follows. The child, without 
any especial warning, begins to vomit, and at first the vomitus will simply 
be the remains of food which still happen to be in the stomach. It will 
continue to vomit quite regularly every fifteen or thirty minutes. This may 
last for ten or twelve hours ; the intervals then grow longer, and sometimes 
the vomiting will cease for twelve or fifteen hours and then begin again. 
Occasionally a little mucus appears in the vomitus, but not to any great 
extent. As the disease progresses, a slight amount of bile usually appears 
in the vomitus. A very prominent symptom is thirst, the child crying con- 
tinually for water, and vomiting it soon after it is taken. As a rule, the 
temperature in these cases is normal or subnormal. The pulse varies, but is 
very apt to be slow, sometimes intermittent, and may become w^ak. After 
the first twenty-four hours the child emaciates rapidly, looks very ill, and 
becomes apathetic. 

Unless the disease is unwisely treated by endeavoring to introduce food 
or drugs into the stomach, it will usually prove to be self-limited, and will 
run its course in two or three days. In some cases the length of the attack 
is much shorter, being comprised within twenty-four hours, while in others 
it may last for many days. The recovery is often as sudden as was the 
onset of the disease. As soon as the vomiting has stopped, the appetite 



842 PEDIATEICS. 

returns ; there are no special symptoms of indigestion ; the child takes its 
food well, and the emaciation disappears rapidly. Relapses occasionally 
take place. 

Diagnosis. — The diagnosis of persistent vomiting is often difficult, 
more on account of a lack of sufficient knowledge concerning the disease 
than from much evidence of the existence of the diseases which it is 
supposed to simulate. In these cases an examination of the abdomen should 
be made at once, including a rectal examination. This is necessary in order 
to exclude such sources of vomiting as intussusception and appendicitis. 
The absence of any marked increase in the temperature and a careful 
examination of the thorax will in most cases exclude the sudden onset of 
some pulmonary disease or of the acute infectious diseases. The disease 
which is most commonly suspected in these cases is tubercular meningitis. 
In some instances, after the disease has lasted for two or three days, the 
resemblance to tubercular meningitis may be quite striking ; but if the 
whole course of the affection is taken into consideration, the diagnosis soon 
becomes clear. In persistent vomiting the face and general appearance of 
the child indicate nausea rather than the apathy which would be present 
in tubercular meningitis. The mind also, in contradistinction to what takes 
place in the latter disease, is clear, the child remaining quiet merely because 
it is exhausted. The great thirst which I have already mentioned as being 
present in persistent vomiting also aids materially in the differential diag- 
nosis from tubercular meningitis. The sudden onset of the vomiting in a 
previously healthy child is quite different from the slow progress and the 
occasional vomiting of a cerebral type met with in tubercular meningitis. 

After the first twenty-four hours, persistent vomiting is readily differen- 
tiated from attacks of simple indigestion, as where the vomiting arises 
from indigestion the stomach is speedily relieved, and the vomiting does 
not continually recur without apparent cause, as is the case where persistent 
vomiting is present. 

Persistent vomiting is also very commonly diagnosticated as acute 
gastric catarrh, but in the latter disease the heightened temperature, coated 
tongue, pain, and tenderness in the epigastrium will, after the first twenty- 
four hours, allow us to differentiate the two diseases. 

Prognosis. — The prognosis of persistent vomiting varies according to 
the age of the individual affected. In young infants, especially in those 
whose vitality is weak, it may prove to be a very serious disease, from the 
exhaustion which invariably arises in the first twenty-four hours. The 
rule is that the younger the individual the more prostrating and serious 
is the disease. Even older children are at times so prostrated by the con- 
tinuous vomiting that grave doubts are often entertained as to their 
ultimate recovery. In general, however, the prognosis in these cases is 
good, and, although I have met with a number of them, I have never seen 
the disease result in death. 

Treatment. — The treatment of persistent vomiting is essentially star- 



DISEASES OF THE STOMACH. 843 

vation during the first twenty-four hours. The child should be kept per- 
fectly quiet in a darkened room. If after twenty-four hours the vomiting 
still continues, or even before if there appears to be much exhaustion, or if 
the child is restless and sleepless and has an intermittent pulse, hydrate of 
chloral and bromide of potassium, dissolved in brandy and water, should 
be given by the rectum. These are intended to procure sleep and to stimu- 
late the nervous centres. As a rule, however, the child is quiet, and sleeps 
in the intervals of the vomiting, and, as the disease usually attacks an 
mfant or a child who has been perfectly well, cardiac weakness is not com- 
monly shown in the first forty-eight hours, ^o food and no drugs should 
be given by the mouth. After forty-eight hours, small enemata of pepton- 
ized milk can be given, and when the disease appears to have run its 
course, as it often does in three or four days, small quantities of a carefully 
modified alkaline milk can be tried cautiously by the mouth. A mistake is 
usually made in the treatment of the disease in feeding by the mouth too 
early. 

I shall speak of a few illustrative cases of this disease which have come 
under my notice, as a knowledge of them will be of great use to you in 
your practice. 

The first (Case 407) was an infant, eight months old, strong and healthy, whose food had 
always been the milk of a wet-nurse. Without any previous symptoms the infant began to 
vomit, and continued to vomit every fifteen minutes for twelve hours. The intervals then 
became longer, and the vomiting ceased entirely on the third day of the attack. During 
the attack the infant emaciated rapidly, so that it looked as though it were in the last 
stages of some wasting disease. It lay perfectly quiet and slept in the intervals of the 
vomiting. Its mind was clear. Its temperature was subnormal, and its pulse weak and 
intermitting. It was treated by rectal enemata of brandy, peptonized milk, and bromide 
of potassium. 

The infant had several attacks of this kind in each of the following years of its life 
until it was five or six years old, when it would sometimes go for six months or a year with- 
out an attack. As it grew older the attacks became less severe, and when it was ten years 
old they ceased entirely. 

The next case (Case 408) was that of a girl, twentj^-two months old, whom I saw in 
consultation with Dr. Joseph Stedman, She was perfectly well before the vomiting began. 
Her temperature was normal : the pulse was slightly accelerated at first, and later became 
slow and intermittent. During the first four days of the attack the vomiting was almost 
continuous, and she became so weak and exhausted on the fourth day that it was feared 
she might die suddenly. There were great restlessness, dilated pupils, throwing of the head 
backward, slow pulse, and normal respirations. The emaciation was rapid. The urine was 
scanty. On the fifth day, the vomiting having continued, she fell into a state of collapse, 
the pulse was hardly perceptible, her countenance was ghastly, and her extremities were 
cold. At one time after a severe attack of vomiting she became cyanotic, and was almost 
stifled by tenacious mucus. This, when vomited, appeared to invade the larynx, S(i that 
it seemed as though her life was saved a number of times by the prompt action of an 
experienced nurse. On the sixth day the vomiting grew less, and on the seventh day 
it ceased. She was not, however, able to be up and about until the eleventh day, and was 
not entirely well until the third week from the time that she was attacked. The treatment 
in this case was the same as in the previous one. 

A third case, a boy (Case 409), nine years old, was seen by me in consultation with Dr. 
F. B. Harrington. This boy was attacked suddenly with vomiting as desciibed in the 



844 PEDIATRICS. 

previous cases. The duration of the attack was about two weeks. The prostration was 
extreme, and the boy's strength was supported solely by enemata, as at no time during the 
two weeks could anything be retained by the stomach. 
These last two cases were unusually protracted. 

Acute Gastric Indigestion (Acute Dyspepsia). — By indigestion we 
mean a disturbance of the gastric secretions interfering with the function of 
the stomach to such a degree as to cause morbid symptoms. Exactly what 
this disturbance is in infants and young children has not yet been clearly 
proved. The cause of acute indigestion in infants, and in almost every 
case in young children, is the food which is given to them. This is 
especially noticeable in the first year. The ages at which indigestion most 
frequently occurs in this period are, first, in the early days of life, when the 
equilibrium of the breast-milk has not been established ; second, in the 
middle of the first year, Avhen the breast-milk is so apt to be replaced or 
supplemented by some other food ; and, third, at the end of the year, when 
entirely new articles of diet are usually given to the infant. 

Symptoms. — The symptoms of acute indigestion are extreme pallor, 
nausea, eructations of gas, a general appearance of discomfort, due probably 
to the pain induced by the development of gas in the stomach, with its 
resulting distention, and finally vomiting. If the diet is exclusively of 
milk, the vomitus will usually contain large curds of the coagulated pro- 
teids. In connection with the gastric disturbance there is commonly consti- 
pation, although sometimes there may be a relaxed condition of the bowels. 
The fsecal discharges accompanying these attacks are of an abnormal color, 
usually a mixture of green, white, and yellow, and of sour odor. There is 
little or no fever. At times the symptoms are so severe that the infant 
looks as though it were going to die. In rare cases also reflex symptoms of 
a serious aspect may arise, such as I have already described when speaking 
of asthma dyspepticum (page 750). 

Diagnosis. — Sometimes the diagnosis is obscured by the absence of 
vomiting, but the pallor and nausea are usually of sufficient prominence to 
allow us to decide that the seat of the disturbance is the stomach. An 
emetic, such as one-half to one teaspooonful of wine of ipecac, usually re- 
lieves the symptoms promptly and makes the diagnosis clear. 

Treatment. — The treatment of acute indigestion is to empty the 
stomach, to give a mild laxative in order to clear away the undigested 
food, and to regulate the diet. The laxative may be one or two tea- 
spoonfuls of castor oil, an eighth to a tenth of a grain of calomel for four 
or five doses, or a teaspoonful of liquid magnesia. If the food has been 
breast-milk, an analysis of the milk should be made at once, and the 
proper modification of the milk, according to the rules which I have 
already given you, should be carried out. If the infant is being fed on an 
improperly modified milk, or if improper food of any kind has been given 
to it, a recurrence of the attacks can easily be obviated by a modification 
of the elements of the food which seem to have produced the disturbance. 



DISEASES OF THE STOMACH. 845 

Thus, in a number of cases I have found that Avhenever the infant's food 
was modified so as to raise the percentage of the sugar above o, acute indi- 
gestion followed. In like manner in certain cases the percentage of the fat 
had to be reduced to 3, or perhaps 2.5, and the proteids even as low as 
0.45, for a number of weeks until the digestive function of the stomach 
became normal. 

In older children the symptoms are similar to those which I have just 
described, and the diagnosis and treatment the same as in the infant, for 
there is no way by which an attack of acute indigestion can be so surely 
prevented from recurring as by at once placing the child for several days on 
an exclusive diet of a milk modified in such a way as to contain a percent- 
age of from 2 to 5 of fat, 5 to 6 of sugar, 1 to 2 of proteids, and 10 of 
lime water. 

Chronic Gastric Indigestion (Chronic Dyspepsia).— If the attacks 
of acute indigestion are allowed to occur frequently from lack of proper 
treatment, a subacute or chronic form of the disease develops. 

Symptoms. — In infants the symptoms of chronic indigestion are much 
less severe than those of the acute form. The infant is apt to vomit after 
taking its food, to be restless, fretful, and either to lose in weight or not to 
gain. Its sleep will be very much disturbed, apparently by pain from 
flatus. In chronic indigestion the bowels are apt to be constipated, but this 
is not always the case. The chronic indigestion of older children presents a 
somewhat different aspect. The temperature is at times somewhat height- 
ened. The tongue is apt to be coated, and the breath to have an odor. These 
children do not vomit so frequently as do infants. They lose in weight, 
become fretful, and get tired easily. 

Treatment. — I have seldom found the use of any especial drug to be 
of much benefit in these cases of chronic indigestion. In quite a number 
of cases of both acute and chronic indigestion, before anv food is introduced 
into the stomach it is often wise first to wash out the stomach thoroughly 
(lavage). This procedure is especially indicated if the indigestion has pro- 
duced continuous vomiting. 

The technique of washing out the stomach is very simple. A soft rub- 
ber catheter with a double eye, No. 21 French scale, as recommended by 
Dr. Holt for infants under six mouths, and No. 25 for older children, is 
attached by means of a piece of glass tubing 7.5 cm. (3 inches) long to 
another rubber tube which is 50.5 cm. (20 inches) long attached to a funnel, 
preferably of hard rubber, and capable of holding from 90 to 120 c.c. (3 or 
4 ounces). The infant is seated upright in the nurse's lap, with its head 
inclined forward and resting on the nurse's arm. Its arms are control knl 
by a towel pinned around them. The catheter, having been wet with warm 
water, is easily passed over the base of the tongue into the stomach. .Vs 
there is often considerable gas in the stomach, the funnel should be raised 
as high as possible above the infant's head, in order that the gas may ]ki>s 
out from the stomach. From 90 to 120 c.c. (3 or 4 ounces) of sterilized 



846 PEDIATRICS. 

water should be poured into the stomach by means of the funnel. The fun- 
nel is then depressed below the level of the stomach, and the gastric contents 
will in this way be siphoned out. As the curds are often too large to pass 
through the eye of the catheter, a number of washings will often be necessary 
to break them up. By washing out the stomach not only are the irritating 
substances which are producing the indigestion removed, and the mucous 
lining of the stomach left free to recover its normal condition, but it is 
also possible to have a chemical examination of the contents made. Clini- 
cally, however, the latter is not necessary, although it is of great interest 
physiologically. No food should be introduced into the stomach for at 
least two hours after the washing. The washing of the stomach is almost 
entirely free from danger, and, in addition to being an important part of 
the treatment of indigestion, is often of great use where poisonous substances 
have been swallowed. 

This method of treating disturbances of the stomach is more valuable in 
young infants than in older children, because the latter resist so vigorously 
that the remedy is often of more harm than good. The tube can, however, 
usually, even in older children, be introduced by aid of the ordinary gag 
which is used for intubation. Two assistants are usually necessary in intro- 
ducing the tube in older children, while in infants one assistant is sufficient. 
In some cases it is found necessary to introduce the tube through the nose. 
The tube should be passed into the throat rapidly, since the gagging and 
vomiting occur chiefly when the tube touches the pharynx. There is 
usually an escape of gas or gastric contents as soon as the tube enters the 
stomach. 

When the inflow of water through the tube is shown to be too rapid, by 
the fact that the infant holds its breath too long, or by its crying, vomiting, 
or coughing continuously, the flow should be stopped for a short time. Care 
must also be taken not to introduce the catheter too far into the stomach, 
as it may bend on itself and interfere with the flow of the returning water 
and gastric contents. If the gastric contents are expelled along the side of 
the tube rather than through it, the tube should be withdrawn until the 
vomiting has ceased. There seems to be no danger of passing the tube into 
the larynx, or of perforating the stomach with it. 

Lavage is contra-indicated where there is cardiac disease or any severe 
pulmonary disturbance, and when the introduction of the catheter continues 
to excite vomiting it should be used with extreme caution. The fact that 
the infant is in a feeble condition is not a contra-indication to this treat- 
ment. 

In connection with lavage it is well to speak of forced feeding (gavage) 
in the treatment of infants and young children. In cases of acute and 
chronic indigestion, and also where a catarrhal condition of the stomach 
is present, the infants at times refuse to take any food Avhatever. This 
does not occur merely where the disturbance is in the stomach : I have 
frequently met with it in severe cases of all kinds of disease. In a 



DISEASES OF THE STOMACH. 847 

number of instances, where the infants would probably have died of starva- 
tion had not gavage been employed, this means of providing for their nour- 
ishment has been very successful. Forced feeding may sometimes have to 
be employed for a number of days, and even weeks, before the child will 
of itself swallow again. 

The technique of gavage is similar to that of lavage. The same appa- 
ratus is employed, but the child should be placed flat on its back in bed, 
and its head held by an assistant. The catheter should be passed into the 
stomach rapidly, the funnel raised up in the air for a few minutes in order 
that the gas may escape, and the amount of food adapted to the age of the 
child should then be poured into the funnel. As the last of the food dis- 
appears from the funnel, the catheter is pinched tightly and quickly with- 
drawn. This precaution is important, in order that the pharynx shall not 
be irritated either by the slow withdrawal of the catheter or by the trickling 
of the remains of the fluid, as vomiting may in this way be excited. 

One of the advantages which has resulted from the use of the stomach- 
tube is the knowledge we have acquired of the time which the food remains 
in the stomach at different ages. Thus, it has been found that during the 
early weeks of life the stomach is nearly emptied in an hour, while in older 
infants two hours are required for the same process. This knowledge is 
especially valuable when we are regulating the intervals of feeding in pre- 
mature infants, and in infants during the first six months of life. These 
intervals I have already given in my lectures on Premature Infants and on 
Feeding. 

Where other means can be employed, they are preferable to the stom- 
ach-tube. I have found in most instances where infants or children refuse 
to take their food that the simplest way of forcing it upon them is to pinion 
the arms with a towel and have the nurse hold the child half reclining 
in her lap. Sometimes an assistant is needed to hold the head, but this is 
often unnecessary. Simply pressing the child's nostrils with the thumb and 
finger will cause it to open its mouth, and the food can then be poured in 
w^ith a spoon, or, as I have done in a number of cases, by means of a dropper 
with a large end. A child two and one-half years old, who has recently 
been under my care, for several weeks would not take any food without 
being forced to do so. Although this child was very ill with pneumonia, 
involving both lungs, it was fed every two or three hours, night aud day, 
by this method. After the first two or three feedings it did not resist, and 
the nose did not have to be pinched, all that was necessary being to threaten 
to do so. 120 c.c. (4 ounces) of milk were, after a little practice, intro- 
duced by means of the dropper into the child's stomach in five or six 
minutes. 

I have found that the most speedy cure of chronic indigestion is to give 
the child a carefully modified alkaline milk. In some cases it will be 
necessary to reduce the fat or sugar, in others the proteids, but in every 
case, as soon as it is determined which of these elements in full strength 



848 PEDIATRICS. 

does not suit the individual digestion, an improvement in the symptoms will 
soon follow the reduction of the percentage of that element. After the 
indigestion has been relieved by this means, other articles of diet adapted 
to the age of the child can gradually be added. 

In addition to the direct treatment of the stomach, the intestinal dis- 
turbance which almost always accompanies the gastric indigestion should be 
relieved by occasionally giving a dose of some mild laxative, preferably one 
of the salts of magnesia. This latter treatment is indicated not only for 
children, but for young infants, because, when there is gastric indigestion, 
the undigested food which passes into the duodenum is a prolific source of 
intestinal disturbance. This, by adding to the discomfort of the child, 
weakens it, and tends to prolong the gastric indigestion. 

ORGANIC. — The organic affections of the stomach may be divided 
into non-inflammatory and inflammatory. They are, in my experience, 
very rare in comparison with the functional diseases which I have just 
described. 

Non-inflammatory. — The non-inflammatory conditions of the stomach 
comprise a diminution in the size of the organ, mechanical dilatation, ulcers, 
and new growths. 

Contraction of the Stomach. — In certain cases the gastric capacity 
of the stomach is decidedly diminished. This diminution in the size, as a 
rule, depends upon a lack of use, such as occurs in infantile atrophy. Suffi- 
cient food to fill the stomach is not taken, and in this way the stomach is 
not called upon to perform its normal work. In cases, also, where there is 
continuous vomiting, this same lack of use may produce a diminution in the 
size of the stomach. These cases are of pathological rather tlian of clinical 
interest, as they can seldom be diagnosticated, and their treatment is essen- 
tially that of the special disease to which they are secondary. 

Dilatation of the Stomach. — Dilatation of the stomach is rather more 
common in infancy than in older children. It may rarely arise from some 
malformation, such as a stenosis of the pylorus, but in most cases is the 
result of errors in feeding. It is more apt to occur where the infant is not 
nursed, unless especial care is taken to give the infant the quantity of food 
which is adapted to its age and gastric capacity. When the infant is nursed, 
the breast seems to provide the amount of food which is suitable. Dilatation 
from errors in feeding may be caused by the fact that the food is not adapted, 
either in quality or in quantity, to the age of the individual iufaut. Where 
j:he quality is at fault, the nutrition of the tissues of the stomach is inter- 
fered with, and its walls become weak, and are thus more easily distended by 
the gas which results from the abnormal changes in the food. In this way 
dilatation occurs. This class of cases is notably represented in the disease 
rhachitis, where dilatation of the stomach takes place very readily. 

W^here the quantity of the food is not properly adapted to the size of 
the stomach, dilatation can take place in even a healthy infant. I have 
already demonstrated to you, in my lectures on Development and Feeding, 



DISEASES OF THE STOMACH. 



849 



the size of the stomach at different ages, and the amount of food which it 
normally holds. I shall, therefore, not repeat what I explained to you 
so fully at that time, but shall merely impress upon you the great impor- 
tance of carefully regulating the amount of food which is given at each 
feeding during the first year of life. 

Pathology. — The pathological condition which exists in cases of 
gastric dilatation is well represented in this stomach (Fig. 108). 

Fig. 108. 




Dilated stomach. Rhachitic infant, 7 months old. (Natural size.) 



It was taken from an artificially fed rhachitic infant (Case 410), seven months old, 
who died under my care at the Boston City Hospital. The gastric capacity in this case 
was 300 c.c. (10 ounces), which corresponds to the gastric capacity of an infjint twelve 
months old. You will notice the shape of the stomach, which is very significant of the 
symptoms I shall presently describe. 

You see that the lesser curvature is not much altered, while the greater curvature is 
very much increased. The pathological condition of the tissues is such as would be expected 

54 



850 PEDIATRICS. 

from general malnutrition. In such diseases as rhachitis there is a stretching of the muscular 
fibres, as well as an atrophied condition of the entire gastric walls. 

Symptoms. — The symptoms of dilatation of the stomach are essentially 
those of chronic indigestion. Vomiting is quite frequent, and continues 
until the stomach has been entirely emptied, when a period of relief comes, 
to last until fresh irritation arises from another supply of food. Abdominal 
pain, flatulence, and general discomfort are prominent symptoms. Emaci- 
ation and rapid loss in weight also occur. In some cases, in young infants, 
convulsions may arise, apparently due to the reflex disturbance which is 
produced. There are usually considerable thirst and loss of appetite. 
When the dilatation is of a high grade, the vomiting may occur only after 
considerable intervals, — twenty-four to forty-eight hours, — during which 
time the food does not pass out through the pyloric orifice to any degree, 
but collects in the stomach. 

If you will look at this dilated stomach (Fig. 108), you will readily 
understand the mechanism of these symptoms. Under normal conditions 
the stomach, as I have already shown you (page 85), is somewhat tubular 
in shape and oblique in position. The food thus easily passes through the 
cardiac to the pyloric orifice. In dilatation of the stomach, on the contrary, 
the greater curvature is so much increased and depressed below the level of 
the pyloric orifice that a pouch is formed. The food, collecting in this 
pouch as though it were at the bottom of a well, has to be practically 
pumped, by the contraction of the muscular walls, up to and through the 
pyloric orifice. The already weakened stomach thus has to perform work 
for which it is not fitted, and finally is relieved by spasmodic vomiting. 
When only the small amount of food adapted to their normal gastric 
capacity is given to young infants whose stomachs are dilated, a large space 
of empty stomach is left above the level of the liquid which has entered 
the stomach. This creates a feeling of emptiness and general discomfort, 
so that the infant appears to be hungry when, in fact, it is only suifering 
from the feeling of incomplete filling of the stomach. 

Diagnosis. — On inspection the abdomen is seen to be distended and 
tense, and on percussion to be highly tympanitic in its upper part. Succus- 
sion is not an especially valuable diagnostic sign in dilatation of the stomach. 
Succussion is so frequently found in many conditions, and is so likely to be 
confounded with that which occurs in the colon, that it cannot be relied upon. 
The outlines of a normal stomach when somewhat distended vary so much 
in infancy that the results of percussion are often very misleading. When, 
however, the tympanitic resonance is found to extend below the line of the 
umbilicus, we may suspect that we are dealing with gastric dilatation. In 
infancy the cardiac end of the stomach is so slightly developed that any 
great increase in the area of gastric percussion to the left is an important 
aid in making the diagnosis. 

The differential diagnosis is to be made chiefly from dilatation of the 
colon. In many cases when the colon is dilated it is impossible to deter- 



DISEASES OF THE STOMACH. 851 

mine whether the stomach is also dilated, since under these circumstances the 
colon can almost completely cover a largely dilated stomach. In older 
children, in cases where the diagnosis is uncertain I have found a valuable 
means of determining the presence of dilatation to be artificial distention. 
This can be done without harm or discomfort to the child by giving it first 
one half of a seidlitz powder and then the other half, so as to allow the 
chemical combination to take place in the stomach. Except in certain cases 
where it is very necessary to determine ^^'hether the stomach is really dilated, 
this is not a procedure which I am in the habit of adopting. In most cases 
in infants and children clinically satisfactory results can be obtained by 
percussion. 

Prognosis. — If the dilatation is due to congenital stenosis of the 
pylorus the prognosis is very unfavorable. In other cases the prognosis 
depends upon whether the condition arises from improper amounts of food 
or from some disease, such as rhachitis. In the former class the prognosis 
is good, and the stomach under a proper regulation of the diet soon resumes 
its natural size. In the second class it is not so good, and, as a rule, the 
stomach will remain more or less distended until the disease which causes 
the dilatation has been cured. 

Treatment. — If the case is an obstinate one, lavage is an important 
part of the treatment. In many cases, however, good results are obtained 
simply by regulating the quality and quantity of the food. In both infants 
and children carefully modified milk is the food from which the best results 
are obtained. When the food is first given in the proper amount it will, as 
I have just told you, not fill the stomach nor satisfy the demands of the 
infant. Under these circumstances the infant will be very restless, and will 
often cry almost continuously from the time of one feeding until the next. 
You must impress upon the nurse that these signs of discomfort are liable 
to last for a number of days, until the stomach has more nearly resumed its 
normal size, and that an additional supply of food must not be given to it. 



I shall report to you the case of an infant (Case 411), four months old, which illustrates 
dilatation of the stomach as it occurs in the first year of life. This infant, a male, was well 
and strong at birth. It was not nursed, but was fed on a mixture of milk, cream, and water. 
It was an unusually yigorous infant, and is reported to haye neyer been satisfied with the 
small quantities of food suitable to its age. When it was three weeks old it was giyen 150 
to 180 c.c. (5 or 6 ounces) at each meal. Somewhat later, in its second and third months, it 
gradually developed sj-mptoms of indigestion, and when I was called to see it was in a very 
serious condition. It had been having frequent and prolonged convulsions. At times when 
it was in the convulsions it would fiill into a state of collapse, the pallor of its face would 
be extreme, and it would look as though it were dying. On examination, nothing abnor- 
mal was found in the thorax. The entire abdomen was found to be distended, especially 
in the upper part, whore the gastric tympany was pronounced and easily marked out by 
percussion. The percussion showed the stomach to be dilated, and to extend below the line 
of the umbilicus and fjir to the left of the median line. 

The infant was given small amounts of food at frequent intervals. For the fii-st two or 
three days it cried and screamed for more food, but the convulsions ceased, its general con- 
dition improved, and by the end of the week the distention of the stomach had subsided 



852 



PEDIATRICS. 



very markedly and the infant had become tranquil. From this time there was no recur- 
rence of the symptoms. 

I have here in the wards to show you a colored boy (Case 412), six years old. 

Case 412. 




Dilatation of atomach. Age, 6 years. 



This child is markedly rhachitic. He is reported to have been in fair health, though 
delicate, until one month ago, when he began to have persistent vomiting. He has lost 
greatly in weight, has been very restless at night, and has had continual borborygmi. 

Physical examination shows marked abdominal enlargement. On percussion the gas- 
tric tympany is found to extend downward as far as the umbilicus, 7.8 cm. (3 inches) to the 
right of the median line and 10.4 cm. (4 inches) to the left. I have marked this percussion 
line, which represents the greater curvature of the stomach, with spots. As the resonance 
of the colon is also exaggerated in this case, and as its differentiation from that of the stomach 
is somewhat difficult, because it evidently overlaps the lower border of the stomach, I shall 
endeavor to eliminate this obstacle to diagnosis by mechanical means. You see that the 
child readily takes half of this seidlitz powder which has been dissolved in water. The 
other half, which has also been dissolved in water, is next swallowed. As the combination 
of the two salts takes place in the stomach you can easily hear with the stethoscope the 
chemical action which is resulting. The child shows no signs of discomfort, and saj^s that 
he does not feel any pain or any more tenderness in the epigastrium than before the powders 
were taken. The outline of the upper part of the stomach can now be fairly well seen, and 
on percussion the line of the greater curvature is found to be 2.5 cm. (1 inch) below the 



DISEASES OF THE STOMACH. 



853 



line of tlie umbilicus, the colon having been pushed out of the way by the distended 
stomach. I have indicated the line of greater curvature by a broad white line, and in this 
way we determine that the stomach is really dilated. 

(Subsequent history.) In this case it was not found necessary to wash out the stomach 
more than once or twice, for as soon as small amounts of food were given at frequent inter- 
vals the vomiting ceased and the stomach gradually resumed its normal size. At the end 
of two months the child left the hospital free from any abnormal gastric symptoms. 

Ulcers. — Ulcers of the stomach in infancy and early childhood are very 
rare, but cases have been reported. They may be non-inflammatory or 
inflammatory, the distinction between the two often being very difficult to 
make. 

Through the kindness of Dr. Northrup I am enabled to report to you 
such a case, occurring in a female one year old who was under his care. I 
also have here the stomach (Fig. 109) to show you. 

Pig. 109. 




Follicular ulceration of stomach. Female, 1 vear old. 



The infant (Case 413) was under treatment for one month. It had vomiting and diar- 
rhoea. During the first week that it was in the hospital its temperature varied from 38.8** 
to 39.4° C. (102° to 103° F.), after that being normal or subnormal. The respirations 
varied from 40 to 50, and the pulse from 120 to 140. In the second week it began to refuse 



854 PEDIATRICS. 

its food and to emaciate. The diarrhoea continued, and the vomiting was persistent. The 
vomitus was somewhat brownish in color The child died of exhaustion. 

On examining the stomach you see that the lining mucous membrane is covered with 
small ulcers, varying in size from dots to 1 cm. (f inch) in diameter. The lesions appear 
to be follicular ulcerations. You will notice that in the middle of the specimen is a much 
larger ulcer, which has perforated the gastric wall. There is no evidence of an inflamma- 
tory condition, and the cause of these lesions is unknown. There is, however, a certain 
degree of necrosis around the ulceration. 

New Growths. — Morbid growths in the stomachs of infants and young 
children are so extremely rare that their occurrence need merely be re- 
ferred to. 

Inflammatory. — The inflammatory lesions of the stomach may be 
either acute or chronic^ and are termed gastritis. 

Acute Gastritis. — Acute gastritis may be divided into (1) gastritis 
catarrhalis, (2) gastritis corrosiva, and (3) gastritis pseudo-membranosa. 

Before describing these forms I must state that, in my experience, the 
cases in which a catarrhal condition of the stomach can be proved to exist 
are very limited in comparison with those in which the functional disorders 
which I have already described are present. I believe that in a large num- 
ber of cases which are spoken of as gastritis catarrhalis no catarrhal condition 
is present, and that they would be much better classified under the heading 
of indigestion. I am led to believe this from the numerous cases in which 
a diagnosis of gastritis has been made during life, and in which, at the 
autopsy, no definite lesion has been found. When, however, gastritis is 
present, as a rule the acute form is more common in infants, while the 
chronic form is more frequent in children towards the age of puberty. 

Gastritis Catarrhalis Acuta (Acute Gastric Catarrh). — The cause of 
acute gastric catarrh is somewhat obscure, but it is usually supposed to 
arise from an exaggerated form of indigestion, or from the presence of irri- 
tants of various kinds, among which too hot food has been cited. 

Pathology. — The pathological lesions which characterize acute gastric 
catarrh are hyperaemia of the gastric mucous membrane, hypersecretion of 
mucus, small punctate hemorrhages, and slight thickening of the mucous 
coat. 

Special work on this subject has been done by Epstein in Germany and 
by Booker in this country. According to Booker, where a catarrhal con- 
dition of the gastric mucous membrane is present the milk remains much 
longer in the stomach than under normal conditions, — possibly four or five 
hours, or even more. A microscopic examination of the gastric contents 
in these cases shows various micro-organisms, and sometimes epithelial and" 
pus cells. The small number of bacteria found in cover-slip preparations 
from the contents of the stomach affords a most striking contrast to the large 
number of bacteria which, under like circumstances, are found in the faeces. 
Symptoms. — Two forms of acute gastric catarrh are usually described, 
the division being made according to the length of the febrile period. In 
one form there is little or no fever, while in the other the temperature is 



DISEASES OF THE STOMACH. 855 

high. The first class, or afebrile form, is by far the more common, and is 
what is usually spoken of as gastritis catarrhaKs. It is subacute rather 
than acute. According to my experience, it is difficult and almost impos- 
sible to state definitely the symptoms of the afebrile form of acute gastric 
catarrh. They so nearly approach those which occur in cases of indiges- 
tion, where we believe no gross pathological condition exists, that we should 
always be guarded in our use of the word catarrh. Pain is so common a 
symptom in all gastric disturbances, the existence of tenderness is so diffi- 
cult to determine in infants and young children, and a h^-persecretion of 
mucus is so often known to occur without the presence of an inflammatory 
condition, that there does not seem to be any one symptom upon which we 
can rely. The general picture of the disease which is su23posed to represent 
acute gastric catarrh is that of fever, nausea, vomiting of food mixed T\-ith 
mucus and at times of mucus alone, and a sense of tenderness, uneasiness, 
and discomfort in the epigastrium. There may be frontal headache, a 
rather swollen, coated tongue of somewhat glassy appearance, and often a 
slight follicular pharyngitis. There is loss of appetite, with, at times, hic^ 
cough and eructations of gas. The bowels are usually constipated at first, 
but after three or four days diarrhoea may result. 

Where the infant or child seems prostrated for a few days, and sick 
beyond what would naturally be expected in an acute attack of indigestion, 
and where, in combination with a somewhat heightened temperatiu-e, fre- 
quent vomiting of mucus occurs, we are justified in supposing that we are 
dealing with a catarrhal condition. 

Treatment. — The treatment of cases of this kind is the same as that 
which I have described in speaking of indigestion. Food should be with- 
held from the stomach for many hours, for, as I have just told you in 
speaking of the pathological conditions which occur in gastritis catarrhalis, 
the food remains so long in the stomach that a fresh supply at short inter- 
vals will act as an additional source of irritation. In those cases which do 
not respond readily to long intervals of rest and to feeding with small 
quantities of a modified alkaline milk, lavage will prove of value. Much 
judgment should be used as to the time when the food is to be increased in 
strength, for unless great precautions are taken relapses will frequently occur, 
and as a result the disease may finally become chronic. After convalescence 
has been established the child will begin to gain in weight. Some simple 
tonic, such as nux vomica, is usually indicated for a week or ten days until 
the child has recovered its streno;th. Duriuo; the beo-innino: of the attack, 
when food is being withheld, if the child is made very restless by extreme 
thirst, teaspoonful doses of iced soda water can be given, but with caution 
and as seldom as possible. The second or febrile form of acute gastric 
catarrh is rare, but is of much more serious import than that of which I 
have just spoken. It is characterized by high fever, 39.4°, 40°, 40.5° C. 
(103°, 104°, 105° F.). The invasion is very acute. It may last for two 
or three weeks and show severe and alarming symptoms. There may be 



856 PEDIATRICS. 

active vomiting, delirium, and sopor in tlie beginning, so that it will be im- 
possible to determine whether or not one of the other acute febrile diseases is 
developing. The characteristic symptoms of gastric catarrh develop later, 
and then the differential diagnosis is easily made. Instead of the cessation 
of the vomiting in the first twenty-four or forty-eight hours, as in scarlet 
fever, and of the continuance of the cerebral symptoms, as in meningitis, 
or of the development of pulmonary symptoms, as in pneumonia, the vom- 
iting continues, though not quite so frequent as in the beginning, the mind 
becomes clear, and the symptoms point to the abdomen rather than to the 
head or the thorax. The onset of pneumonia in some cases, though in my 
experience rarely, simulates this disease. The pulse is rather irregular. 
There is usually constipation at first, followed by diarrhoea. 

The prognosis is good, except in very debilitated children. 

The child should be placed in a darkened room, soothing applications 
applied to the abdomen, and small quantities of iced soda-water given. 
The food should be given as I have just described in the other form of 
gastritis catarrhalis ; that is, in very limited quantity and at long intervals. 
If there is much exhaustion, stimulants are indicated. 

Gastritis Corrosiva Acuta. — Corrosive lesions of the mucous membrane 
of the stomach are at times produced by swallowing irritants, such as 
arsenic, carbolic acid, and caustic fluids. In these cases the lesions are 
usually found on the summits of the rugse. 

The treatment is by washing out the stomach with large quantities of 
water, administering the proper antidote, and feeding the child on a liquid 
diet so modified as to be as little irritating as possible to the injured mucous 
membrane. 

Gastritis Fseudo-membranosa. — The membranous form of gastritis is 
extremely rare in infancy and childhood. Cases have been reported, notably 
those of Wollstein. In these cases the congestion of the rugae was very 
marked, and along the greater curvature extended over an area of a number 
of inches. There was a thick grayish-green membrane, with some erosions. 
The gastric walls were much thickened. 

The symptoms of gastric disturbance in these cases are often almost 
entirely absent, but there may be vomiting, pain, and tenderness in the 
epigastric region, and insatiable thirst. A pathognomonic symptom would 
be the vomiting of shreds of membrane, with or without an admixture of 
blood. This symptom is, however, extremely rare, because the membrane is 
usually adherent, so that a differential diagnosis is often impossible. 

The prognosis is very unfavorable, and the treatment is purely symp- 
tomatic. 

Gastritis Catarrhalis Chronica (Chronic Gastric Catarrh). — Chronic 
gastric catarrh, as I have already stated, is not usually met with in infancy, 
but occurs in later childhood. It is especially common in the summer 
months, and is generally the result of neglect or of improper treatment of 
the acute form of the disease. 



DISEASES OF THE STOMACH. 857 

Pathology. — The pathological condition which is found in chronic 
gastric catarrh is the result of long-continued hypersemia. There is often a 
slaty discoloration of the mucous membrane, with cellular infiltration of the 
submucosa. In addition to this there is usually found a considerable quan- 
tity of tough mucus. 

Symptoms. — The symptoms are not so clearly defined as in the acute 
form of the disease, but are variable and of a rather sluggish type. The 
tongue is apt to be much coated and the breath to have a disagreeable odor. 
There is considerable abdominal distention after meals, so that the children 
complain that their clothes feel uncomfortable. 

Frontal headache is apt to occur. The children gradually grow thin and 
anaemic. They vomit at irregular intervals, and are usually constipated. 
There is often a slight cough, and the symptoms, so far as the stomach is 
concerned, may form so small a part of the general picture of the disease 
that the child is not infrequently brought to the physician on account of its 
cough and because it is supposed to have some pulmonary affection. 

Prognosis. — Although the disease is often somewhat intractable, the 
prognosis under proper treatment is good. It may last for three or four 
months ; but in many cases which are usually considered chronic gastric 
catarrh it has seemed to me there is no organic lesion, but that the disease is 
functional in its character, and the prognosis consequently very good. 

Treatment. — It is often necessary in these cases to precede the treat- 
ment by carefully washing out the stomach. We must remember, however, 
that a considerable quantity of mucus may be in the stomach which cannot 
be removed by washing, so that if the symptoms continue after one or two 
washings, even though no mucus is returned by the tube, we should repeat 
this treatment from time to time. The diet should be an alkaline modified 
milk, with a low percentage of proteids, if necessary peptonized, and a 
moderate percentage of fat and sugar. The percentages of the different 
elements should be increased as improvement in the gastric symptoms takes 
place, and later broths and milk can be tried. Symptomatically in certain 
cases pepsin, dilute hydrochloric acid, and bismuth are occasionally indicated. 
A valuable tonic in the after-treatment of these cases is nux vomica. 



858 PEDIATRICS. 



LKCTTURE XIvV. 

DISEASES OF THE INTESTINE. 

Diseases of the intestine may be divided into three classes, — develop- 
mental, functional, and organic. 

DEVELOPMENTAL. — Certain malformations and malpositions of the 
intestine occur as a result of abnormal development. The malformations 
are of that class which I have described in a previous lecture when speak- 
ing of Meckel's diverticulum and of imperforate rectum (pages 426-433). 
Malpositions are met with in infants where there is a transposition of the 
abdominal organs. 

DIARRHOEA. — As vomiting is the most significant symptom of gastric 
disturbance, so diarrhoea resulting from increased intestinal peristalsis is the 
most characteristic symptom of intestinal disturbance. Diarrhoea is always 
a symptom, never a disease. There seems to be a predisposition to diarrhoea 
in the first two years of life, which decidedly lessens as the child grows 
older. The most frequent time for the occurrence of diarrhoea is during 
the summer months. 

PROPHYLAXIS. — Much can be done at all seasons of the year to 
prevent the occurrence of diarrhoea, but prophylaxis is of the utmost im- 
portance in warm weather. The children should be protected by proper 
clothing from extremes of heat and cold, and from dampness. They should, 
if possible, be taken away from crowded or unclean districts in cities and 
towns during the hot weather, and have the advantages of fresh country 
or sea air and good hygienic surroundings. Both the quality and the 
quantity of the food should be carefully regulated. The milk and the 
water should be pure and sterile, and in very hot weather an extra amount 
of water should be allowed and the solid food somewhat diminished in 
amount. Uncooked fruits and food are contra-indicated in very hot 
weather. Especial attention should be paid to any slight indisposition 
which may arise in hot weather, as it may render the child more vulner- 
able to the various causes of diarrhoea. 

INTESTINAL CONTENTS.— Before speaking in detail of the various 
diseases of the intestine, I shall describe to you some of the more important 
abnormal appearances which are met with in its contents. These changes 
are significant of diseased conditions, though not necessarily of any especial 
disease. The intestinal contents should be studied in regard to their color, 
consistency, composition, odor, and amount. 

Color. — I have already described to you (page 117) the normal appear- 
ances of the faecal discharges, and I shall now show you some that are 
abnormal. 



DISEASES OF THE I>^'TESTINE. 859 

This specimen^ which is numbered 16 (Plate III., facing page 112), is 
what is usually spoken of as clay-colored. This clay color may be due to 
a diminution in the amount of bile which enters the intestine, or to un- 
digested fat. This color is abnormal, and is usually met with in intestinal 
diseases of a subacute or a chronic type. It does not necessarily indicate a 
serious condition, however, as even a small plug of mucus may interfere 
with the flow of bile into the duodenum. 

This specimen, which is numbered 17, is the light green color, which 
may be simply a change that has taken place after the fseces have been 
passed, and which often is not significant of any especial pathological condi- 
tion. It may, however, show that the changes which have taken place in 
the food during its passage through the intestine have not been entirely 
normal. It is the least important of the changes which take place in the 
color of the intestinal contents. The colors in these next two specimens, 
numbered 18 and 19, are what may be seen in a more serious disturbance of 
the enteric tract. These colors may appear in any of the intestinal dis- 
eases which are accompanied by diarrhoea, but are significant of no especial 
disease. They are merely to be considered pathological in contradistinction 
to the normal colors in these other specimens, 3, I, 6, 7, 8, 9, and the 
beginning abnormal condition represented in 17. 

Besides these shades of green there are a great many varieties of color 
produced by the mixture of green, yellow, white, and brown. These are 
valuable merely as instructing us whether we are dealing with a normal or 
an abnormal condition of the intestinal contents, and, as I have already 
told you in my general remarks on diagnosis, are not significant of any one 
disease, either functional or organic. Much variety in the color also arises 
from the admixture of blood, mucus, and shreds of membrane. In this 
connection it is well to remember that the yellowish-white lumps seen in 
undigested faeces are often made up of fat as well as of proteid material. 

The color of the intestinal contents may also be changed by the admin- 
istration of various drugs, such as iron, which causes a more or less black 
color. Bismuth gives the colors which you see in these three specimens 
numbered 12, 13, and 14. Number 12 is the color which was produced by 
giving to an infant 0.18 gramme (3 grains) of bismuth every two hours 
for six doses; number 13, where 0.24 gramme (4 grains) of bismuth was 
given every two hours for six doses ; and number 14, where the latter 
dose had been omitted for twenty-four hours. The size of the dose and the 
intervals between its administration will of course produce dilfereut shades 
of color. 

Where the solids of the intestinal contents are much reduced in propor- 
tion to the serum, as in cases of acute and frequent diarrhcea, the discharges 
become more and more fluid, and sometimes almost entirely lose their color 
and look like water. 

Consistency. — In the first year of life, or while the infiint is having 
only milk for its food, the consistency of the faecal discharges is inter- 



860 PEDIATEICS. 

mediate between solid and fluid, and the discharge, as a rule, is smooth and 
free from lumps. As the infant begins to take other forms of food and 
a mixed diet, the fsecal discharges gradually become more solid. The 
consistency of the faecal discharge is abnormal when it becomes liquid, as 
in diarrhoea, or when it is too solid, as in constipation. 

Composition. — In addition to the various substances which make up 
the food which enters the intestine, the faecal discharges contain bile, mucus, 
epithelial remains, and many bacteria. In diseased conditions they may 
also contain certain morbid elements, such as blood, pus, and membrane. 
In intestinal diseases of both an acute and a chronic type the mucus may be 
very largely increased, but it cannot be considered to be especially charac- 
teristic of an inflammatory condition, as the secretion of mucus apparently 
may be very much increased in purely functional conditions. The bacteria 
are very numerous and of many varieties, but in most cases the detection of 
any especial form of these organisms does not aid us in diagnosticating the 
especial disease. Notable exceptions to this statement are where one finds 
the typhoid bacillus, the comma bacillus, and the amoeba coli. 

Odor. — While in the normal faecal discharges of infants fed entirely on 
milk the odor is comparatively slight, it becomes much stronger as other 
articles of food, either of a starchy or of a proteid nature, are added to it. 
Where an abnormal condition exists, various changes take place, as in acid 
fermentation, where the odor is sour, and in albuminous decomposition, 
where the odor is very foul. Although these conditions can scarcely as yet 
be considered of great diagnostic importance, they are sufficiently so for us 
to make use of them in the diagnosis and treatment of intestinal diseases. 
Thus, where acid fermentation is supposed to be present, a reduction in the 
percentage of the sugar, and perhaps of the fat, is indicated, while where 
albuminous decomposition is suspected a reduction of the proteids in the 
food is called for. 

Amount. — In estimating the amount of the faecal discharges we must 
consider the total amount in twenty-four hours, and not the large or small 
amount which may occur at one movement. The total amount in twenty- 
four hours is of much importance in both the acute and the chronic diseases 
of the intestine. In the acute diseases, the more frequent the diarrhoea and 
the larger the amount the greater is the exhaustion and the worse is the 
prognosis. In some chronic diseases the total amount of faecal discharges 
may be very large. In these cases the larger the total amount the less has 
been the absorption and the worse is the prognosis, for this condition is an 
indication that the child is being starved from a lack of power to absorb 
the food which has been given to it. 

FUNCTIONAL. — The functional diseases of the intestine may be 
classed as acute, chronic, and eliminative. 

Acute (Simple Diarrhoea). — The acute functional disturbances of the 
intestine may be of nervous origin, or they may arise from intestinal indi- 
gestion. 



DISEASES OF THE INTESTINE. 861 

Nervous. — In certain infants and children whose ner^^ous system is 
easily affected exaggerated peristalsis causing diarrhoea may arise from a 
number of causes without any known lesions, fever, or gastric disease. 
Among these causes may be cited heat, cold, and fright. In like manner in 
these individuals foreign bodies, food or otherwise, may by simple reflex 
irritation cause such a nervous disturbance as to produce diarrhoea. In these 
cases either the small or the large intestine, or both, may be affected, and, so 
far as we know, the mucous membrane is either normal or simply hyperaemic. 
There is more or less serous exudation. These cases are rare in comparison 
with the other forms of diarrhoea, such as those which are caused by bacteria, 
and in them intestinal decomposition and intestinal inflammation are not 
present primarily. 

Symptoms. — The symptoms of simple diarrhoea are very apt to appear 
suddenly. There is usually abdominal pain, not, as a rule, of great in- 
tensity. At first there are two or three rather liquid yellowish-brown dis- 
charges occurring at intervals of perhaps one-half or one hour, and often 
accompanied by considerable flatus. There is a certain amoimt of restless- 
ness, pallor, and exhaustion. Vomiting is rare. The temperature, as a 
rule, is not raised, or is raised very slightly. The pulse is rather weak and 
somewhat quickened. The number of the discharges may be eight, ten, or 
twelve in the twenty-four hours, and these soon become watery and of a 
lighter color, but are seldom green. The odor is somewhat increased, but 
not excessively. These symptoms, unless they are exaggerated by improper 
food or by bad treatment, usually disappear in a few days. 

Treatment. — If there is a known cause, such as some intestiual irri- 
tant, a dose of castor oil or calomel may be given, but, as a rule, this is not 
necessary. The child should be kept in bed. Food should be withheld 
for some hours. A few drops of tinctura opii camphorata and hot appli- 
cations to the abdomen are indicated for pain. If there is a tendency 
for the diarrhoea to continue, the subnitrate of bismuth may be given, 
and in some cases where there are signs of exhaustion a stimulant may 
be needed. For several days the diet should be simply milk heated for 
twenty minutes at 75° C. (167° F.) and containing ten per cent, of lime 
water. 

I must impress upon you that these simple diarrhoeas, especially in hot 
weather, should never be allowed to continue, as they render the intestine 
vulnerable to the more serious diseases, which may at any moment gain an 
entrance in this way. 

Tubular. — In addition to these more common intestinal affections of 
nervous origin is one that is called tubular. This disease is so rare 
before the age of puberty that it need only be alluded to. It is a condition 
of the mucous membrane of any part of the intestine in which an exudation 
of mucus takes place in such a way that masses closely sinuilating a mem- 
brane may form on the surface. When discharged through the rectum 
they are sometimes found to have formed a cast of the intestine. These 



862 PEDIATRICS. 

masses are mostly made up of mucus, and may occur in shreds of greater or 
less extent as well as in the tubular form. 

The disease is supposed to be of nervous origin. The symptoms are 
pain, tenderness, and tenesmus. The temperature is usually normal. 

The prognosis, as a rule, is good, although in some cases the disease may 
be much prolonged. 

The treatment is to be directed essentially to improving the general 
health and the nervous condition, the local treatment being merely symp- 
tomatic. 

Indigestion. — Disturbances arising from intestinal indigestion in most 
cases may be located in the duodenum. It has yet to be proved that any 
pathological lesion is present in these cases, and for the present they must be 
looked upon as functional. 

These cases vary in their symptoms with the individual and according 
to the part of the duodenum which is most involved. In one set of cases 
the disturbance of digestion is shown simply by the increased peristalsis, 
such as I have just described in the nervous cases, but here the evidence 
points to an undigested condition of improper articles of food which have 
been given and which appear in the discharges. 

The treatment of this class of cases is very simple, and consists in first 
giving a laxative and then regulating the diet according to the age of the 
individual. 

What is usually spoken of as a " bilious attack'^ represents another class 
of cases. This condition is very rare in infancy, and usually occurs in 
middle and later childhood. In these cases, in addition to the increased 
peristalsis and evidence of undigested food, there are frequently icterus and 
vomiting of bile. In addition to these symptoms there may be headache 
and excessive nausea. The icterus is usually slight in degree, but often is 
marked and is noticeable in the conjunctivae and in the urine. Here is a 
specimen (Plate III., facing page 112, No. 11) which I have numbered 
11, and which shows the staining of bile on the napkin of an infant during 
an acute attack of indigestion involving the duodenum and accompanied by 
icterus. The temperature in these cases is usually slightly raised for a 
few days and then becomes subnormal. In a certain number of cases the 
faecal discharges become clay -colored. This color is often produced mechan- 
ically, as I have already explained. 

Although the symptoms in these acute attacks may often appear quite 
serious, the prognosis is always good. In some individuals they are liable 
to recur even when the diet and the general health are well attended to. 

In the treatment of this class of duodenal disturbances we must con- 
sider that the fats in the food are in all probability especially liable to 
prolong the disease by not being properly digested so long as the function 
of the duodenum is involved. We should, therefore, in treating these cases, , 
lessen the amount of fat given in the food. I have found that the treatment 
which most speedily shortens the attack is (1) total restriction from food 



DISEASES OF THE INTESTINE. 863 

for twelve hours, with the administration of small quantities of cold, steril- 
ized water if the thirst is excessive, and (2) the administration of small 
quantities of milk modified as in this prescription (Prescription 77) : 

Prescription 77. 

Fat 0.16 

Sugar 6.00 

Proteids 3.00 

Lime water 10.00 

The mixture to be heated to 75° C. (167° F.) for twenty minutes; from 
120 to 180 c.c. (from 4 to 6 ounces), according to the age, to be given every 
three hours. 

Under this treatment the icterus usually passes away in a few days, and 
the child can then soon be given its ordinary food. 

Chronic. — The chronic functional diseases of the intestine may be the 
result of acute nervous disturbances, or they may arise from a number of 
prolonged attacks of acute indigestion. Incontinence of faeces and consti- 
pation are also forms of chronic functional intestinal disturbances. Under 
this same heading we can class infantile atrophy. 

Nervous. — In the chronic form of nervous functional intestinal disturb- 
ance either the small or the large intestine may be affected, and, as I have 
already stated in describing the acute form, the condition of the mucous 
membrane, so far as we know, is either normal or hypersemic. The causes 
are the same as in the acute form. This class of cases is not especially 
common, as they are merely a prolongation of the symptoms which I have 
already sufficiently described in speaking of the acute cases. The treat- 
ment of these cases is essentially with stimulants and care of the general 
health. 

Indigestion. — The chronic form of functional intestinal indigestion plays 
an important part in intestinal diseases, especially when it is located in the 
duodenum. Chronic indigestion of the duodenum constitutes a disease of 
itself, and is one of the most difficult to cure which we meet with. It has 
usually been spoken of under the names of chronic gastro-duodenal catarrh 
and mucous disease. We at present, however, have no proof that either 
a catarrhal or any other pathological lesion of the mucous membrane is 
present in these cases, and the weight of evidence is in favor of the view 
that the disease is purely functional. 

Etiology. — The etiology of chronic duodenal indigestion is in many 
cases obscure, but in a large number of cases it is produced by the con- 
tinual administration of food which is not adapted to the age or digestive 
capabilities of the child. It is at times met with as a sequela of some 
exhausting disease, such as typhoid fever, pneumonia, or one of the acute 
exanthemata. It very rarely occurs in early infancy, being usually met 
with during the middle and later periods of childhood. 

Symptoms. — The symptoms are at first somewhat varied. The disease 



864 



PEDIATRICS. 



may be preceded by a number of attacks of gastro-enteric indigestion of 
a subacute character. A tendency to nausea and vomiting extending over a 
number of months may sometimes precede the full development of the 
disease. The gastric disturbance, however, is not marked, and is probably 
a reflex condition depending upon the functional disturbance of the duo- 
denum. At first the faecal discharges show merely the various changes 
which occur in ordinary indigestion, sometimes manifesting a tendency to 
diarrhoea and sometimes to constipation. The color of the discharges at 
this early period is not significant of anything beyond ordinary indigestion, 
and is usually a mixture of yellow, white, and green. As the disease 
progresses, certain characteristic symptoms arise and definitely mark its 
presence. Mucus begins to appear in the fsecal discharges, and soon be- 
comes quite large in amount. 

I have here a specimen (Fig. 110) of the shreds and masses of mucus 
which appear in the discharges, and which, in combination with the other 
symptorhs which I am about to describe, are so significant of the disease 
that it will be well for you to examine them closely. 



Pia. 110. 




a case of chronic duodenal in 



With this hypersecretion of mucus, which I shall again impress upon 
you is not necessarily an indication of an inflammatory condition, the child 
begins to be fretful, to be wakeful at night, to grind its teeth, and to lose in 
weight. The skin becomes dry, and there is usually a coexisting follicular 
pharyngitis which causes a short, dry cough. The child gets tired easily, 
and complains of pain in the epigastrium after eating. The abdomen is apt 
to be distended and tympanitic. There are frequently frontal headache, a 
coated tongue, and a disagreeable odor to the breath. The fsecal movements 
noAV begin to become clay-colored, and the skin to assume a sallow tint, with 
at times a slight amount of icterus. Sometimes an exacerbation of all the 
symptoms takes place, resulting in an acute attack of indigestion. These 
symptoms, varying in intensity, and sometimes ceasing to be prominent for 
days or weeks, usually continue for months, and in intractable cases may 
last for years. The temperature in this disease is usually normal, some- 
times subnormal, but may of course, where an exacerbation occurs, be 



DISEASES OF THE INTESTINE. 865 

somewhat raised. The pulse is usually moderately slow. Sometimes a 
subacute form of bronchial catarrh accompanies the disease, but it does not 
appear to be a part of it. There is often a craving for large quantities of 
sugar. 

Diagnosis. — When all the symptoms are present, the diagnosis of 
chronic duodenal indigestion is not difficult. The appearance of the child 
is characteristic. Its eyes are dull and heavy ; its skin is dry and harsh and 
sometimes slightly icteric, while the loss of flesh, the distended and tym- 
panitic abdomen, and the coated tongue are more marked than in any other 
disease. Where, in addition to this picture, an examination of the faecal 
discharges shows them to be clay-colored and to contain a large amount of 
mucus, the diagnosis is quite evident. The disease which is most com- 
monly mistaken for chronic duodenal indigestion is pulmonary tuberculosis. 
The short, dry cough, the emaciation, and in some cases the bronchial 
catarrh, often make parents and physician fear that this serious disease is 
present. If, however, the entire history of the case is studied carefully, 
pulmonary tuberculosis can soon be eliminated. 

Prognosis. — The prognosis of chronic duodenal indigestion is in 
most cases good. Even in those cases which last for a period of years 
the health is usually entirely restored. Where, however, the disease has 
lasted for a long time, and the child is in a very debilitated condition, the 
prognosis becomes more serious. 

Treatment. — The treatment of this disease is essentially by diet, and 
not by drugs. Such articles of food should be given as will be chiefly 
digested by the stomach and will not tax the duodenal digestion. This of 
course indicates a proteid diet, and contra-indicates the administration of 
starches, sugars, and fats. In order not to tax the disturbed duodenum by 
overloading it in its weak condition, small amounts of food at shorter 
intervals than usual are found to produce a better result than the regular 
three or four daily meals. The diet which I have found most valuable in 
treating these cases is a milk so modified as to have a low percentage of 
sugar and fat, a high percentage of proteids, and ten or fifteen per cent, of 
lime water. Soups of various kinds, and meat, can also be given, and the 
crust of French bread in limited quantity. A valuable adjuvant to this 
treatment, as a mild astringent and stimulant, is a small amount of claret, 
preferably given in seltzer Avater. The meals should be five in the twenty- 
four hours. It is exceedingly difficult in most cases to keep the child 
on this diet, but if it is rigorously enforced the duration of the disease 
will be decidedly shortened. As the epigastric pain and the amount of 
mucus in the discharges grow less, the diet may be somewhat varied by 
giving fish and eggs, and the percentage of lime water in the milk may be 
reduced to five. As relapses occur very easily, however, it is generally 
best to continue with this rigid diet until the faecal discharges have become 
normal in color and have not shown the presence of mucus for a number 
of weeks. In mild cases where there is much constipation, small doses of 

65 



PEDIATRICS. 

calomel, or any mild laxative, are indicated. Podophyllin can also be given, 
as in this prescription (Prescription 78) : 

Prescription- 78. 

Metric. Apothecary. 

Grammae. 

R Podophyllin 

Alcohol 3 



06 R Podophyllin gr. 

75 Alcohol ^i. 



M. M. 

Sig. — Prom 3 to 5 drops, according to t]ie age of the child, in the morning and evening, 
lessening the dose if it causes more than two discharges daily. 

Where there is a tendency to diarrhoea, small doses of bismuth are found 
to be valuable. 

Tincture of nux vomica freely diluted in water and given in doses of 
a few drops after each meal seems in some cases to be of value. 

The remainder of the treatment is essentially symptomatic, and if the 
children are weak and anaemic tartrate of iron and potassium can be given. 

During the whole course of this disease cod-liver oil is contra-indicated, 
but where the disease has been cured and the child is left weak and emaci- 
ated it may in some cases be beneficial. Its administration, however, should 
always be carefully supervised, as it may cause a relapse. 

I have here a child (Case 413a), three years old, who has an attack of chronic duodenal 
indigestion, and who represents very well the general picture of this disease. I wish you 
to notice especially in this case the distended abdomen, the dry, harsh skin, which is 
slightly icteric, and the evident loss of flesh. She has been affected by the disease for the 
past two months. The prominent symptoms have been epigastric pain and clay-colored 
movements with a hypersecretion of intestinal mucus. 

This little girl (Case 414), six years old, represents also a case of chronic duodenal 
indigestion. 

She was healthy at birth, and was nursed until she was thirteen months old. During 
her first year she had an attack of bronchitis, and since then she has been subject to cough. 
Previous to this attack she has never had any intestinal disturbance. Her abdomen is said 
to have been always rather prominent. From her earliest infancy she has been a nervous 
child, has not slept well, has talked much in her sleep, and has occasionally walked in her 
sleep. Six months ago she began to lose in weight, and two months ago her cough became 
quite severe. She then had an attack characterized by vomiting for twenty-four hours, fol- 
lowed by anorexia, fever, languor, and apathy ; the bowels became constipated, the skin 
icteric, the urine dark-colored, and the fgecal movements light-colored. She had an intense 
craving for sugar, and ate all that she could lay her hands on, so that she had to be watched 
very closely to prevent her satisfying this morbid appetite. Her appetite for other articles 
of food was poor. You will notice that the abdomen is distended and tympanitic, and that 
the tongue is coated. The breath has a disagreeable odor, and there is loss of flesh. There 
is a follicular pharyngitis, which is evidentl}^ the cause of the cough, as nothing abnormal 
can be detected in the lung or the nose. 

(Subsequent history.) The child was placed on the following diet. Her first meal was 
milk so modified as to contain fat 2, sugar 3, proteids 4, lime water 10. "With this meal she 
was allowed to have a small amount of the crust of French bread. The second meal con- 
sisted of broth and the crust of French bread, and one ounce of claret in half a tumbler of 
seltzer water. The third meal consisted of meat, the crust of French bread, claret, and 
seltzer water ; the fourth, of soup, the crust of French bread, claret, and seltzer water ; the 



DISEASES OF THE INTESTINE. 867 

fifth, of tlie modified milk and the crust of French bread. After each meal three drops of 
tincture of nux vomica were administered. 

This diet was carried out rigorouslv for one week. At the end of that time the child 
looked much better, the urine was clear, the ftecal movements began to resume a more nat- 
ural color, the mucus in the discharges was very much lessened, and the abdomen was not 

Case 4U. 




Chronic duodenal indigestion. Female, 6 years old. 

so much distended. The tongue was less coated, and the cough had almost disappeared. 
It was also found that the craving for sugar had much decreased. The diet was then 
slightly increased in variety. At the end of a month the child had recovered entirely, 
and some weeks later an ordinary diet at the usual times was given to her. 

Incontinence of Faeces. — Incontinence of ileces is a condition in which 
there is a loss of power of the sphincter to control the movements. It may 
be due to organic or to functional causes. The organic causes are very rare 
in childhood, and will best be spoken of in connection with the diseases in 
which they occur. Functional incontinence may arise from nervous influ- 
ences, such as excessive mental fatigue, or from stretching of the rectum 
from habitual constipation. 



868 PEDIATRICS. 

This boy (Case 415), eleven years old, represents the nervous type of the disease. He 
has been much overworked at school, has been made to study a number of languages, and 
has been allowed to take only a very limited amount of exercise in the open air. He has- 
completely lost control of the sphincter ani, and, as you see, is very anaemic and weak. 
Nothing abnormal has been found on a physical examination. 

(Subsequent history.) The boy was taken from school, relieved entirely from hi& 
studies, and kept in the open air most of the day. Under this treatment, in addition to the 
administration of tartrate of iron and potassium and claret, he improved rapidly, and in two 
months was entirely well. 

This boy (Case 416), seven years old, came to the Children's Hospital, during the 
service of Dr. Lovett, with a history of incontinence of faeces lasting over a year. He 
illustrates the condition of incontinence from habitual constipation, as the incontinence 
was found to depend on stretching of the rectum by impacted faeces. 

The rectum was emptied by a dose of castor oil and an enema each day. At the end 
of a week the boy had ceased to have involuntary faecal movements, and he has since con- 
tinued well. 



Constipation. — By constipation is meant a condition in which the 
movements of the bowels do not take place as often as is normal for the 
individual, and in which the consistency is abnormally increased. Constipa- 
tion is a symptom, and not a disease. It is a relative term, as what would 
be normal in one individual may be abnormal in another. During the first 
year of life two or three daily discharges may be considered normal ; in the 
second year two discharges ; and in the third and fourth years one discharge 
is the usual number. The causes of constipation are varied, and in many 
cases rather obscure. Mechanical obstruction may produce constipation. 
Thus, as the sigmoid flexure is proportionately long in infancy, flexions 
may occur, with resulting obstruction. The usual cause of constipation, 
however, is of a functional character, and may be spasm^odic or atonic. 

Spasmodic. — The spasmodic cases are rare, but should be recognized, as 
they frequently cause much disturbance of the child's general health. In 
these cases the fsecal movements are usually much increased in size and con- 
sistency. This condition produces so much pain and irritation in the rectum 
that the child endeavors not to have a movement. 

Atonic. — The atonic is the most common form of constipation, and 
simply represents a sluggish condition of the intestinal peristalsis. It is 
usually caused by food which is not adapted to the digestion of the special 
child. Thus, in some cases cereals, such as oatmeal, seem to produce this 
condition, although in a large number of cases they relieve it. 

As a rule, constipation can be easily cured, but some cases are ex- 
tremely intractable and last for a number of years. When the intestine 
has become more developed and assumed the relative proportions found in 
adult life, the constipation is very apt to pass away, so that we may in 
almost every case give a favorable prognosis. Constipation can usually be 
cured by strict attention to the regulation of the diet by the use of fruits, 
vegetables, and cereals. In young infants an increase of the fat in the 
milk will in quite a number of cases relieve it. Variation in the percent- 
age of sugar is occasionally found to be eflicient in curing the constipa- 



DISEASES OF THE INTESTINE. 869 

tion. Many drugs have been employed in the treatment of constipation, 
but, as a rule, we should endeavor not to use them, as they are very apt 
to be only temporary in their action. In connection with the diet, I place 
most reliance upon enemata and laxative suppositories, such as those made 
of glycerin or of gluten. 

Infantile Atrophy (Marasmus). — Infantile atrophy is essentially a 
disease of infancy and early childhood. It is a condition in which extreme 
atrophy of all the muscular tissues takes place without demonstrable dis- 
ease of any of the organs. It is apparently due to a vice of absorption, 
although this has by no means been clearly proved. 

The primary cause of infantile atrophy is unknown. In a number of 
cases the disease seems to be secondary to grave intestinal disturbances, 
whether of toxic or of organic origin. 

Pathology. — The pathological conditions which are found in cases of 
infantile atrophy are exceedingly unsatisfactory, and have not given us 
much information concerning the disease. There is an atrophic condition 
of all the muscles. !N^othing abnormal is found in the various organs 
which can be especially attributed to this disease. It is supposed by some 
pathologists that the lymph-glands are enlarged ; but this enlargement does 
not seem to be a prominent feature. No pathological condition of the 
mesenteric lymph-glands has been found, and the atrophy of the mesenteiy 
around them is so great that their increase in size may be seeming rather 
than real. In the intestine, although in some cases there is considerable 
atrophy of the mucous membrane and the submucous tissue, no character- 
istic lesion has been proved to be present. 

Symptoms. — The symptoms of infantile atrophy are those of starva- 
tion. The infant begins to emaciate, and extreme loss of weight is the 
prominent feature of the disease. The food is apparently digested well, 
and the fsecal movements are often of a normal character ; in many cases 
the total amount in the tAventy-four hours is abnormally large. The appe- 
tite is, as a rule, lessened, the temperature is normal or subnormal, the pulse 
is weak, and the respirations are generally normal. Usually the infant 
seems not to suffer from pain, being sometimes quite apathetic, but in some 
cases extreme fretfulness and restlessness occur. Vomiting, apparently of 
a reflex nature, is at times a prominent symptom. The weight continues 
to diminish, and without any other symptom the infant may die from 
exhaustion. 

Diagnosis. — The diagnosis of infantile atrophy is chiefly to be made 
from ordinary starvation and from general tuberculosis. From the former 
it is soon differentiated by its lack of response to good food. In the 
ordinary cases of starvation which result either from improper food or from 
lack of food, a diet carefully adapted to the age of the infant or child is 
soon followed by rapid improvement. The diflerential diagnosis from 
general tuberculosis is at times exceedingly difficult. I have had under 
my care in the hospital in adjoining beds an infant with infantile atrophy 



870 PEDIATRICS. 

and one with general tuberculosis. In these two cases the symptoms and 
course of the diseases were so identical that it was impossible to differ- 
entiate the two diseases except at the autopsy. On physical examination 
nothing abnormal could be found in either case except extreme emaciation. 
In both cases the temperature was slightly raised. 

Prognosis. — The prognosis of infantile atrophy is bad, especially 
during the first year of life. Even under the most careful treatment 
it is always a very intractable disease. Under special forms of treatment, 
however, which I shall presently mention, the prognosis is much better 
than when these cases receive the old and routine treatment of cod-liver 
oil internally and by inunctions. 

Treatment. — The treatment of infantile atrophy is essentially by 
such a modification of the constituents of the milk as to promote intestinal 
absorption, and without drugs. Although, as I have already stated, it is 
not entirely proved that the morbid condition is that of a lack of absorp- 
tion, yet my clinical results are most favorable when the disease has been 
treated on this principle. After experimenting in a large number of cases 
by modifying the different constituents of the milk in various ways, I 
have arrived at the following conclusion : a mixture should be given 
which contains a low percentage of fat, a high percentage of sugar, and a 
moderate percentage of proteids. The low percentage of fat is given on 
the supposition that the infant will increase in weight and thrive on a small 
proportion of fat, provided it is absorbed. I have found that when higher 
percentages of fat are given the infant continues to lose in weight. The 
administration of cod-liver oil is not indicated in these cases, for it is 
only by a precise adjustment of the percentage of the fat in the food to the 
individual power of absorption that good results can be obtained. The 
sugar of high percentage and the proteids of normal percentage seem to be 
digested and absorbed provided they are combined with a low percentage of 
fat, since by this combination the nutritive properties of the sugar and of 
the proteids are made use of The prescription which I usually write in 
the beginning of the treatment of these cases, where they occur in the first 
year of life, is the following (Prescription 79) : 

Prescription 79. 

Fat 45 

Sugar 6.00 

Proteids .... 1.00 

Lime water 5.00 

After the infant has begun to gain in weight I usually increase the per- 
centage of the fat, but for a number of weeks I do not raise this percentage 
above 1 or 2. When the infant has once begun to gain steadily the power 
of absorbing fat is rapidly regained, and percentages such as are in this 
prescription (Prescription 80) can then be given : 



DISEASES OF THE INTESTINE, 871 

Prescription 80. 

Fat 3.00 

Sugar 7.00 

Proteids 2.00 

Lime water 5.00 

The same treatment can be carried out when the disease occurs in chil- 
dren in their second and third years, but in these cases it is usually possible 
to increase the percentages of the different elements more rapidly, and after 
two or three weeks to begin with other articles of diet, such as beef juice, 
broths of various kinds, and finally, with caution, cereals. 

These special modifications of the milk do not, of course, suit every 
individual infant or child, and when the treatment with them is not success- 
ful, each of the elements of the milk must be carefully changed and different 
combinations of these elements tried until the individual idiosyncrasy of 
absorption in the special case has been discovered. 

I have here a case of infantile atrophy of high grade to show you. 

This infant (Case 417) is nine months old. 

Case 41' 




Infantile atrophy. Female, 'J mcinth* old. 

She has been fed on foods of various kinds, all of which have contained a considerable 
percentage of starch. She is said to have been healthy and plump at birth and during 
the early months of life while she was nursed. After she was weaned and placed on these 
starchy foods she began to lose progressively in weight, and she is now, as you see, in an 
extremely emaciated condition. Physical examination shows nothing abnormal. She has 
four teeth. Her temperature is slightly subnormal, her pulse is regular but weak, her res- 
pirations are normal. On first entering the hospital the bowels were constipated and the 
faecal movements were brown and looked poorly digested. Since being placed on a diet of 
modified milk the movements have become well digested and of normal color, but the total 
amount in twenty-four hours is greater than normal. She has been very fretful, and at times 
vomits, but since her diet has been regulated she is less fretful and is somewhat apathetic. 
On entering the hospital she weighed 2966 grammes (6^ pounds). She has been in the hos- 
pital two weeks, and has gained in that time 1000 grammes. The food which has been 
found to suit her powers of absorption contains fat 1, sugar 5, proteids 1, lime water 5, and 
60 to 120 CO. (2 to 4 ounces) have been given every two hours. 

This is a case in which it is uncertain whether recovery will eventually take place, 
as the emaciation is so extreme, but the prognosis is rendered somewhat favorable by the 
fact that she has already gained 1000 grammes. 

(Subsequent history.) The infant did not increase progressively in weight, but some- 



872 



PEDIATRICS. 



times lost considerably, and at one time it seemed as tliough she could not possibly live. 
After the food had been modified in various ways, she finally began to improve, and when 
she was able to digest and absorb 150 c.c. (5 ounces) of milk so modified as to contain fat 
3.5, sugar 6.5, and proteids 1.5, she improved rapidly, and finally recovered entirely. Her 
temperature, with few exceptions, was normal or subnormal through the whole course of 
the attack. 

Infantile atrophy is so exceedingly intractable a disease, and so greatly 
taxes the patience and skill of the physician, that it may be of interest and 
encouragement to you in treating these cases to see this child whom I have 
had brought to the hospital to show you. 

This boy (Case 418) is three years old. He was healthy at birth, and remained strong 
and well during the early months of his life. He was then fed on a number of starchy 

Case 418. 




Recovery from infantile atrophy of high grade. Male, 3 years old. 



foods, and soon began to lose progressively in weight. He was in the hospital for five or six 
months, and was a typical case of a very high grade of infantile atrophy such as I have just 
shown you. It seemed at one time as though he could scarcely live from day to day, but 
finally the proportions of the food were so adjusted that he began to absorb a small amount 
of nutriment. He then began to gain in weight, and recovered entirely. To-day, in his 
third year, he is, as you see, a remarkably strong, well-developed, and robust child, and, so 
far as I can detect, is in a perfectly normal condition. 

This next infant (Case 419) is also a case of infantile atrophy of high grade. 



DISEASES OF THE INTESTINE. 



873 



This infant entered the hospital one week ago, with a history of having heen fed on 
various foods containing starch from the earliest months of its life. It is said to have been 
healthy at birth and of average weight. On entering the hospital it weighed 2593 grammes 
(5| pounds). It is, as you see, extremely emaciated, and illustrates the more advanced stage 
of infantile atrophy. It is unable to raise its head ; it is apathetic ; its skin is cool and dry ; 
its respirations are shallow ; its pulse is weak, and its temperature is slightly subnormal. It 




Infantile atrophy. Female, 10 montlis old. 

looks as though it could not live many days. A physical examination shows nothing 
abnormal in any of the organs. The faecal movements are rather large in amount, and, 
since its food has been carefully regulated, are fairly well digested. On entering the 
hospital they were still larger in amount and were of a brownish color. It weighs to-day 
2570 grammes (about 5 J pounds), which is slightly less than its weight on entering the 
hospital. This is a case in which the prognosis is very grave, and unless we can soon 
adjust the food to the digestive tract so as to have it absorbed the infant will die in a short 
time. It is being fed on a modified milk in which the percentage of fat is 2, sugar 6, pro- 
teids 1, lime water 10. Although the skin is cool, it is not so cold as in this next child (Case 
420) whom I am about to show you. 

(Subsequent history.) In another week the infant began to gain in weight and evidently 
to absorb its food. Although it had a number of relapses, in which it lost considerably in 
weight, it finally began to gain steadily. At the end of three months it had recovered 
entirely, and, as is seen in this picture (Case 419, II.), was quite plump. 




Infantile atrophy. Recovery after three months. 



In this case the percentage of the fat was finally raised to 4, and that of the sugar to 7, 
but the proteids had to be kept at 1 : the lime water was reduced to 5. 

This infant (Case 420, page 874), a female, one and a half years old, entered the hos- 



874 



PEDIATRICS. 



pital two weeks ago. She then weighed 4281 grammes (9^ pounds). She is said to have 
weighed but 900 grammes (2 pounds) at birth. She was nursed by her mother, who 
apparently had plenty of good breast-milk, and who had two other children whom she had 




Infantile atrophy. Female, 1% years old. 

nursed that were healthy and strong. As the infant did not gain, she was nursed for only 
a short time, and was then fed on various artificial foods. She began to lose in weight, and 
this loss has continued ever since, so that now, as you see, her emaciation is extreme. 

On physical examination I find that the anterior fontanelle is widely open. There is no 




Infantile atrophy, showing extreme emaciation of arms, back, and hips. 



enlargement of the epiphyses of the ankles or wrists, but there is a slight rhachitic rosary. 
Nothing abnormal can be detected in any of the organs. She has four upper and two 
lower incisors. She is very apathetic, and seems hungry, but when food is given to her she 



DISEASES OF THE INTESTINE. 875 

vomits. Since entering the hospital she has lost 519 grammes (1^ pounds). Her skin is dry, 
harsh, and at times quite cold. It has seemed to me ever since she entered the hospital that 
there was no hope of saving her life, and, as she is losing in weight and does not respond to 
the various modifications of the food which have been given to her, the probability is that 
she will soon die. The faecal movements in this case are very large in amount, but since 
entering the hospital have been fairly digested. When she is lifted and placed so that 
you can see her back (II.) you will appreciate the atrophic condition of her muscles, the 
bones seemingly being covered only by skin. The cervical and inguinal glands are 
slightly enlarged, and she has a slight cough. 

(Subsequent history.) The infant lost steadily in weight during the following week, 
when it died. 

The post-mortem examination, made by Dr. Councilman, showed the following con- 
ditions : 

There was extreme atrophy of all the muscles. There were no changes in the mesen- 
teric glands, and they were not enlarged, although the extreme atrophy of the mesentery 
around them made them look so. The liver was normal, and its tissues showed little evi- 
dence of atrophy. The spleen was normal. Sections made from various places in the 
stomach and the intestine showed no changes beyond considerable atrophy of the mucous 
membrane and of the submucous tissue. The thymus gland was atrophied. There was an 
extensive bronchitis in the posterior portions of the lungs, while in some parts there was a 
partial and in others a complete atelectasis. 

Eliminative. — Under the term eliminative disturbances of the intes- 
tine are inckided a number of unexplained and obscure symptoms which 
we at present are unable to classify elsewhere. It is probable that they will 
be more fully understood in the future. It seems as though the intestine 
often acts as an organ for the elimination of various morbid products from 
the economy. The diarrhoea which results from the irritation of these foreign 
elements is not distinguishable from that which occurs when the irritation is 
primarily in the intestine itself. Our knowledge of this class of disturbances 
is, however, so small that I shall merely refer to its possible occurrence. 

ORGANIC. — The organic diseases of the intestine may be divided into 
non-inflammatory and inflammatory. 

Non-Inflammatory. — The non-inflammatory diseases of the intestine 
may be divided into mechanical, fermental, cholera infantum, cholera Asiatica, 
and new growths. 

Mechanical. — The mechanical diseases of the intestine are quite numer- 
ous, but, with a few exceptions, are not of especial importance medically, 
and belong rather to the province of surgery. 

Dilatation of the Colon. — I have already spoken of dilatation of the 
colon so far as it relates to the diagnosis of dilatation of the stomach. In 
comparison with dilatation of the stomacli, dilatation of the colon is very- 
rare, except as a temporary condition which is liable to occur at any time 
from an over-production of gas. 

I have here an illustration (Case 421, page 876) of dilatation of the colon which was 
seemingly caused by a congenital stricture, and in which an artificial anus was made by 
Dr, Halstead. The child recovered from the operation, but later, owing to still further 
obstruction, he had to be operated upon again, and died. 

I show you this case so that if you happen to meet with this rare pathological con- 
dition you will recognize its presence. The extreme distention of the abdomen, which 



876 



PEDIATRICS. 



was tympanitic through its whole extent, the evident obstruction to the faecal discharges, 
and the absence of symptoms pointing towards gastric disease, would suggest a dilatation 
of some part of the intestine, presumably of the colon. 

Case 421. 




hiimiimfamm''' 




Dilatation of colon. Male, 12 years old. 

Volvulus. — By volvulus is meant a twisting or bending of the intes- 
tine. This condition is more apt to occur in early life than later, possibly 
because of the greater proportionate length of the mesentery at this time, 
which allows the intestine greater latitude of motion. It occurs either by 
itself or in connection with the next disease of which I shall speak, from 
which it is to be differentiated by the absence of blood and mucus in the 
discharges. 

Intussusception. — Intussusception or invagination is a condition in which 
a part of the intestine has passed down into another part. Under these cir- 
cumstances there is an outer layer of intestine within which is the part of 
the intestine forming the invagination. Only a small portion of the intes- 
tine may be invaginated, or it may extend from the ileo-csecal valve to 
the rectum. Small invaginations are frequently found at the post-mortem 



DISEASES OF THE INTESTINE. 877 

examinations of infants and young children. These probably take place 
during the death-struggle, as no pathological condition is found in connec- 
tion \Adth them. This form is usually multiple and in the small intestine. 
The form of intussusception which occurs during life is very rare under 
three months, and is most common from the third to the sixth month. At 
this age the large intestine is 'shorter in relation to the small intestine than 
in the adult, while the mesentery is relatively wider, and thus allows much 
greater latitude for misplacement, especially of the csecum and colon. The 
etiology of intussusception is obscure, but it is probably directly due to in- 
creased local peristalsis. 

The pathological condition depends upon the tightness of the constriction 
and the length of time from the beginning of the obstruction. In some 
cases the incarcerated portion of the intestine is so little constricted that the 
bowel remains pervious. In other cases the constriction is so great that the 
tension of the intestinal capillaries quickly becomes so extreme that hemor- 
rhage occurs, and inflammation, with resulting adhesions, is apt to follow 
rapidly. The intestine may not only be invaginated, but may be bent on 
itself, an important point to remember in regard to treatment. 

Symptoms. — The symptoms of intussusception are usually more acute 
in infants than in older children. In infants they are often at first rather 
obscure. Paroxymal pain and discharges of blood from the rectum occur. 
Later the blood is mixed with mucus and looks like currant jelly. There 
is usually vomiting, which may be stercoraceous. The mind is clear, and 
in young infants the face is often tranquil between the paroxysms of pain, 
so that on looking at the infant it would scarcely be supposed that a serious 
condition was present. Later, however, the face grows haggard and the 
eyes become sunken. During the first twenty-four to forty-eight hours, 
and even longer, the infants will often take their food quite readily. 
Tenesmus is at times present. There may be fever, especially when 
inflammation has occurred. The pulse is usually quickened. These 
symptoms all vary, and depend on the amount of the invagination. In 
some cases these are the only signs which indicate that there is abdominal 
disturbance. In many instances, however, either at once or within a few 
hours, a tumor can be felt in the abdomen. 

Diagnosis. — The chief points in diagnosticating intussusception are the 
occurrence of discharges of blood, vomiting, abdominal pam, and the detec- 
tion of an abdominal tumor, usually on the left side of the abdomen. In 
these cases a careful rectal examination should always be made, for a tumor 
can often be found in this way where an external examination has failed 
to detect it. 

Peognosis. — Without treatment the prognosis is unfavorable, though 
there are a certain number of recoveries by spontaneous reduction, or rarely 
by sloughing of the invaginated portion of the intestine, which is then 
passed by the rectum. If death takes place, it usually occurs about the 
third or fourth day, or at any rate within a week, after the incarceration is 



878 PEDIATRICS. 

complete. Where the incarceration is not complete the infant may live for 
many weeks, and in older children in rare instances the disease may become 
chronic. 

Treatment. — The treatment of intussusception when the diagnosis has 
been definitively made should be immediate, as in no other disease does a 
delay result in more serious consequences. Food and cathartics or laxatives 
are contra-indicated. If the infant shows signs of collapse, small quantities 
of brandy-and-water should be given. In the early hours of the attack an 
attempt should be made to reduce the intussusception by hydrostatic press- 
ure. This can be easily done by having the infant's buttocks somewhat 
raised and introducing water under a pressure of about 200 cm. (6f feet) 
by means of a fountain syringe. The water should be lukewarm, and 
should have dissolved in it salt in the proportion of one teaspoonful to a 
quart. The abdomen should be gently rubbed at the same time. In some 
cases this procedure results in a reduction of the intussusception. 

Even where inflammation has not begun and adhesions have not formed, 
the pressure of the column of water may fail to reduce the intussusception, 
because the invaginated portion may be bent on itself, so that the hydro- 
static pressure increases the obstruction rather than relieves it. Where 
adhesions have taken place and where there is great congestion, as some- 
times occurs during the first twenty-four hours of the attack, hydrostatic 
pressure is usually unsuccessful and may be dangerous. If this method has 
failed, the infant should be placed at once in the hands of a surgeon, as 
under these circumstances an early laparotomy will give the most favorable 
results. 

I shall report to you one of the cases of intussusception which have come 
under my care. 

A male infant (Case 422), six months old, nursed by its mother, and previously per- 
fectly healthy, after a slight loss of appetite for several days began to have abdominal pain 
in the morning, and in the middle of the day had a discharge of blood from the rectum 
unmixed with faecal matter or mucus. The bowels had been thoroughly moved on the 
previous day, and there had been no tendency to constipation. During the afternoon there 
were five or six discharges of blood. In the evening the infant looked well and did not 
show any signs of discomfort except occasional slight attacks of abdominal pain and an in- 
disposition to nurse. The rectal temperature was 39° C. (102.2° ¥.). An examination of 
the abdomen externally and by the rectum revealed nothing abnormal. The infant had a 
restless night, vomited several times after nursing, and had six discharges of blood. The 
temperature was 38.3° C. (101° F.), the pulse 135, strong and regular, and the general appear- 
ance good. The abdomen was soft and not tender on pressure, but towards the umbilicus, 
under the left costal border, a rather ill-defined cylindrical tumor could be detected. 

Hydrostatic pressure was employed to reduce the intussusception, but failed. The sur- 
geon who saw the infant on the second day decided to wait twenty-four hours before per- 
forming laparotomy. On the following day the infant died suddenly. 

At the post-mortem examination nothing abnormal was found except an ileo-caecal 
intussusception. An examination of the invagination showed that the retained caecum was 
so twisted that the lower opening was directed to one side of the axis of the intestine, and 
the hydrostatic pressure from below must have simply packed the sac tighter and rendered 
reposition more difficult. The invagination involved 20 em, (8 inches) of the intestine. 



DISEASES OF THE INTESTINE. 879 

The serous surfaces were firmly adherent through their whole extent, and considerable force 
was required to reduce the invagination without tearing it. The reduction, however, was 
successfully accomplished, the adhesions giving way and the intestine being left uninjured 
and apparently healthy. This case illustrates how necessary it is to employ the most 
skilled surgical aid in these cases. 

Hernia. — I have already spoken sufficiently of the pathological con- 
dition represented by hernia^ in my lecture on diseases of the new-born 
(page 430). 

There are a number of lesions which occur about the anus in infants 
and young children which^ though somewhat rare^ should be recognized for 
purposes of differential diagnosis. They are, however, so purely sm-gical in 
their treatment that they need only be mentioned here. 

Fissures. — One of these conditions is that of fissure, which occurs either 
at the anus or more commonly a little distance from the orifice. Pruritus 
and reflex urinary symptoms are common. Defecation is often painful, and 
constipation of the spasmodic type may thus result. 

Prolapse. — Prolapse of the rectum is not uncommon in young children. 
It is usually produced by straining from various causes, especially in 
extreme constipation. The wall of the rectum comes down through the 
anus, and is easily recognized by the appearance of the mucous membrane. 
The prolapse is ordinarily transitory, but in the more severe forms the 
rectum remains down. 

The treatment is to remove the cause. Constipation should be relieved 
first by enemata and then by keeping the movements of the bowels semi- 
liquid by means of gentle laxatives. The child should be kept in bed for 
a number of days, the protrusion being gently pushed back each time that it 
comes down. After reposition it should be kept in place by means of a pad 
and a T bandage. Under this treatment a large number of cases recover. 
The more serious and intractable cases, however, should be referred to a 
surgeon. 

Case 423. 




Congenital prolapse of rectum. Female, 22 months old. 

I have here a case of prolapse of the rectum to show you which has 
been under the care of Dr. C. B. Poi-ter. 



880 PEDIATRICS. 

The infant (Case 423), a female, twenty-two months old, has had this condition of 
prolapse since hirth. Lately the prolapsus has been increasing in size. The infant is not 
fretful, and seems very well. The movements of the bowels are normal through the pro- 
lapsed portion of the rectum. This is one of the more severe types of the disease. You 
see that the prolapsus forms a large rounded tumor covered with reddish mucous membrane 
projecting from the anus. It is about 7.8 cm. (3 inches) long and 4.0 cm. (1 J inches) thick. 
The tumor is not sensitive to the touch. 

Polypi. — Polypus of the rectum is more common in early life than at 
any other period. Hemorrhage from the rectum, when not due to constipa- 
tion, diarrhoea, or fissure, usually arises from polypi. A careful examina- 
tion for this growth should be made where rectal bleeding is frequent or 
large. Rectal polypi are of various sizes, and may be myxo-fibromata or 
adenomata. The surface of the polypus is usually smooth, and the pedicle 
is often long and thin. 

The diagnosis is easily made by a digital examination. 

The treatment is simply to twist or cut off the polypi. The growth is 
not apt to recur. 

Hemorrhoids. — Hemorrhoids are rarely met with in infancy or early 
childhood, but can occur as in later life, and should be treated by the same 
methods. 

Fistulde. — Fistula in ano is not a very common condition in infancy or 
early childhood, but is at times met with. The condition has the same char- 
acteristics as in the adult, and should be treated in the same way. 

Fermental. — The non-inflammatory conditions of the intestine, which 
for want of a better term we speak of at present as fermental, include those 
which arise from acid fermentation and albuminous decomposition, which 
ate produced by micro-organisms. The disturbances which arise from these 
causes represent the greater proportion of the diarrhoeal diseases which 
occur during the warm months of the year. 

Etiology and Pathology. — The causes of fermental disturbance in 
the intestine lie in impure or improper foods and bad hygienic surround- 
ings. In both acid fermentation and albuminous decomposition it is prob- 
able that the small intestine is most affected. The condition of the mucous 
membrane may be normal, or there may be desquamative catarrh. The 
process may go no farther, or it may be followed by inflammatory changes 
in the intestinal mucous membrane. 

The fermental class of cases holds a position midway between the 
nervous forms of intestinal disturbance and the inflammatory forms with 
their pronounced lesions. 

Symptoms. — You can well understand from the great variety of causes 
which give rise to these fermental processes how varied may be the symp- 
toms. The onset may be subacute, with little or no fever and without 
vomiting, or it may be acute and accompanied by a high temperature and 
active vomiting. After a variable period of general discomfort and restless- 
ness, diarrhoea sets in, which varies so greatly as to its frequency, amount, 
color, and consistency that it would be impossible in the present state of 



DISEASES OF THE INTESTIXE. 881 

onr knowledge to divide tiiese variatious clinically. The onset of lermental 
diarrhoea is, however, so often characterized by the toxic symptoms of 
sudden rise of temperature, followed after a day or so by a normal tem- 
pemture, that when we meet with this occurrence we are usually justified in 
eliminating the inflammatory and more serious intestinal lesions. In some 
cases the diarrhoea, although accompanied by much prostration and various 
nervous distm^bances, disappears after a few days ; in others, especially in 
the warm weather, it may last for a number of months. In this fermental 
diarrhoea the color of the discharges is commonly some shade of green 
or greenish yellow, and the odor is often very offensive, sometimes being 
the excessively sour one which is supposed to arise from acid fermenta- 
tion, and at other times the extremely foid one of albuminous decom- 
position. The discharges are usually accompanied by considerable pain 
and a large amount of gas. The symptoms are often so severe that the 
disease has a serious aspect, but in a considerable number of cases after 
the intestine has been thoroughly emptied the temperatiu-e falls and the 
nervous symptoms subside. There is usually rapid and great loss of 
weight. In cases which are not prolonged by fresh irritation or by 
imwise treatment recovery often takes place quite rapidly. 

Diagnosis. — Where the attack is subacute, with slow onset, without 
vomiting, and with infrequent discharges, the diagnosis is not difficult, 
and is to be made from the nervous disturbances, which can usually soon 
be differentiated by the absence of fever and by rapid recovery. Where, 
however, the onset is acute and is accompanied by vomiting, the diagnosis 
must often be held in abeyance, as the symptoms of high temperature, 
vomiting, and diarrhoea may be present in infants and young children in 
the initial stage of a number of acute diseases. The disease from which it 
is to be especially differentiated is cholera infantum. In fermental diar- 
rhoea the prostration is much less, and the temperature after the early hours 
of the attack is much lower. The serous discharges and the continuous 
vomiting which soon arise in cholera infantum are quite different from the 
greenish discharges and the less frequent vomiting which occur in fermental 
diarrhoea. We must remember, however, that cholera infantum and the 
acute inflammatory intestinal diseases are usually preceded for a number 
of days by this fermental form of diarrhoea, and that the special micro- 
organisms which produce the former disease gain an entrance for themselves 
and their toxines by means of the abnormal intestinal conditions produced 
by the fermental changes. You must also remember that gastro-enteric 
symptoms are often so pronoiuiced during the early days of a pneumonia 
that they may mask the presence of that disease. 

Prognosis. — In previously healthy children the prognosis of fermental 
diarrhcea is good. It depends, however, upon the degree and kind of the 
fermental process which is causing the disease, and also on the amount of 
resistance to these processes which the individual possesses. It also depends 
upon the vulnerability of the individual to the other bacteria which may at 

5G 



882 PEDIATRICS. 

any time complicate the disease. The cases of infantile atrophy which 
I have just described to you are especially liable to die when attacked by 
this as well as by any other form of intestinal disturbance. In these cases it 
seems as though the infant were totally unable to resist even a slight amount 
of toxic absorption. The prognosis, therefore, when an already debilitated 
child, or one with infantile atrophy, is attacked by fermental diarrhoea must 
always be guarded. It also depends upon how soon and in what way the 
disease is treated. 

Treatment. — The treatment of fermental diarrhoea is to remove at 
once the source of the disturbance by thoroughly emptying the intestine. 
Where the vomiting is excessive it is sometimes necessary to wash out the 
stomach, but, as a rule, this procedure is not indicated. A dose of castor 
oil, one teaspoonful for infants under one year, and two teaspoonfuls for 
older children, is the best initial treatment. In the more severe cases, 
and where there is a tendency to a prolongation of the acute symptoms, 
irrigation of the intestine is indicated. Food should be withheld for a 
number of hours, — at least half a day, if possible. Stimulants are indi- 
cated where there is much prostration. Where the stomach is so sensitive 
that it does not seem advisable to give castor oil, 0.06 to 0.12 gramme (1 
or 2 grains) of calomel can be given. The only other drug which in my 
experience seems to be indicated is bismuth, which should be given in large 
doses until the disease has run its course and the diarrhoea has ceased. 

I have found, contrary to what has been so often stated, that milk 
can be given after the first twelve to twenty-four hours if it is properly 
modified. It should contain from ten to fifteen per cent, of lime water, 
and at first should have the percentages of its elements considerably re- 
duced. The milk which is used for this purpose must be fresh, since 
it is not sufficient to sterilize it, as the toxic products of bacteria may 
still be present in it and thus add fresh irritation to that which has 
already been produced by the fermentation. In many cases it is impossible 
in the present state of our knowledge to determine what special form of 
fermentation is present. Where acid fermentation appears to be prominent, 
the milk should be so modified as to contain a low percentage of sugar and 
fat, while where albuminous decomposition with its excessively foul odor is 
^met with, the proteids should be reduced to a fraction. Whether this treat- 
ment will in the future be proved to be the best it is impossible to state, 
but on the ground that various forms of bacteria are the cause of these dis- 
turbances, and that the special form of bacteria which is producing them 
has been developed in the food on which it thrives best, it certainly seems 
reasonable, and should be adopted until further light is thrown upon the 
subject. 

Where breast-milk or fresh modified cow's milk cannot be obtained, 
weak animal broths, such as those made from mutton, chicken, or beef, can 
be used. It may perhaps be well to warn you that opium is almost invari- 
ably contra-indicated in these cases, and that serious results may arise from 



DISEASES OF THE INTESTINE. SSZ 

its administration. The peristalsis which occurs as the result of fermental 
irritation is a conservative process of nature, intended to carry away the 
morbid products which have resulted from the fermentation. Under these 
conditions the administration of opium prevents the elimination of the 
poison from the intestine and allows it to remain and produce still further 
irritation, or to be absorbed and give rise to still graver septic symptoms. 
In certain cases where the intestine has been thoroughly emptied, small doses 
of opium in the form of tinctura opii camphorata may be used with caution 
to diminish pain and control the excessive peristalsis which may result 
from nervous exhaustion after the disease has run its course. In these 
cases, however, stimulants are more valuable than opium. 

When a child in the warm weather has once had an attack of fermental 
diarrhoea, it is very apt to have a number of attacks : its diet should there- 
fore be carefully regulated for a considerable period, and, if possible, it 
should be taken to the sea-shore or the country until the return of cool 
weather. 

As especial illustrations of the great variety of fermental diarrhoeas 
which you are liable to meet with in warm weather, I shall call your atten- 
tion to these cases which have come under my notice. 

A child (Case 424), three years old, and perfectly well, was attacked suddenly with 
abdominal pain, nausea, pallor, and prostration. He vomited once or twice, and was 
found to have a temperature of 40° C. (104° F.). Within a few hours he began to have 
frequent faecal dejections of sour odor, lessened consistency, moderate amount, and a 
peculiar dark green color, a specimen of which (Plate III., 18, facing page 112) I have 
here to show you. This green is one of the more common colors met with in fermental 
diarrhoea. At first the discharges took place every hour, and later every three or four 
hours. After the first twenty-four hours the temperature became normal, and in three or 
four days the diarrhoea ceased entirely. 

I have here a case which is also illustrative of this form of fermental 
diarrhoea. 

This infant (Case 425, page 884) is thirteen months old. On entering the hospital 
it was much emaciated, and had a slight diarrhoea, caused apparently by improper food. 
Its temperature was only slightly raised. On examining it nothing else abnormal was 
detected. The diarrhoea was infrequent, and was not accompanied by any other especial 
symptoms. It soon began to improve, gained in weight, and had a normal temperature." 
After it had been in the hospital one week it suddenly began to have diarrhoea character- 
ized by large frequent discharges, of lessened consistency, of foul odor, and of the color 
which you see in this specimen (Plate III., 19, facing page 112). The discharge would 
seem from its foul odor to be an illustration of what is called albuminous decomposition. 
You will notice the mixture of yellow and light and dark green, which is so difierent from 
the dark-green specimen which I have just shown you (Phite III., 18, dicing page 112). 
These colors are, however, only relative, and are not diagnostic. In this acute attack the 
temperature was raised at first, but soon fell to a little above normal. 

The infant has lost greatly in weight, has become extremely emaciated, and looks as 
if it would die. The skin often becomes cold, and the prostration is extreme. These 
symptoms have continued for three or four days, and the number of discharges in the 
twenty-four hours varies from seven to ten. This is the seventh day from the beginning 
of the acute attack, and you see the condition in which it has left the patient. 



884 



PEDIATRICS. 



(Subsequent history.) The symptoms became less severe, and the diarrhoea abated. 
A few days later the diarrhoea stopped entirely, and the infant then gained rapidly in 




Fermental diarrhoea, Male, 13 months old. 

weight and strength. This picture (II.) shows the great improvement which occurred 
in a month. 

Case 425. 
II. 




Fermental diarrhoea. One month after recovery. 

These cases of fermental diarrhoea at times are prolonged for many 
weeks or even months, and thus produce a chronic form of diarrhoea. This 
occurs especially in children who are the subjects of rhachitis, syphilis, and 
general tuberculosis ; also in those with chronic broncho-pneumonia. I 
have already told you that the continuous administration of improper food 
may produce this condition ; so also may improper exposure from insuf- 
ficient clothing. 



DISEASES OF THE INTESTINE. 885 

Cholera Infantum. — Cholera infantum is an acute gastro-enteric dis- 
turbance characterized by intense choleriform symptoms. The term cholera 
infantum should be exclusively restricted to this class of cases, and should 
not be used to designate the many acute and serious attacks of vomiting 
and diarrhoea which are so often designated cholera infantum. It is a rare 
disease in comparison with the fermental diarrhoeas which I have just 
described to you. 

Etiology. — There is not much doubt that cholera infantum is caused 
by a specific micro-organism, although this organism has not as yet been 
determined. It most commonly occurs in the first two years of life, and in 
its development is probably closely associated with the food, for it has been 
noticed that infants who are fed exclusively on pure and sterile foods, such 
as breast-milk, are not liable to be attacked by it. It is also significant 
that the disease occurs only in hot weather. 

Pathology. — The pathology of cholera infantum has not yet been 
satisfactorily determined, but it seems to be a non-inflammatory disturbance 
of the whole gastro-enteric tract, without any gross lesion beyond a desqua- 
mative catarrh, and sometimes hypersemia, of the mucous membrane. 

Symptoms. — The onset of cholera infantum may be sudden, but, as a 
rule, it is preceded by some form of gastro-enteric disturbance, which, by 
causing an irritation of the mucous membrane, renders the infant vulnera- 
ble. When, however, the disease has once gained a foothold, the develop- 
ment of the symptoms is very rapid. 

After a variable but generally short period of restlessness and apparent 
abdominal discomfort, the infant begins to vomit. The vomiting is either 
accompanied or quickly followed by profuse diarrhoea. After the stomach 
and intestine have been emptied of the food which may happen to be in 
them at the time of the onset, the vomitus and the diarrhoeal discharges are 
chiefly serous ; and it is this watery consistency of the discharges which 
especially characterizes the disease. As a rule, the discharges are odorless, 
and consist of serum mixed with epithelial cells and many bacteria. 
Although the disease is more likely to attack weak and debilitated infants, 
yet it often attacks those who are healthy and robust. It may run its 
course to a fatal issue in from twenty- four to forty-eight hours. The ex- 
tremities soon become cold, the skin is pallid or even cyanotic, and the 
face pinched. The abdomen may be a little distended, but is soft, and soon 
becomes rather retracted. The pulse is rapid and difficult to count. The 
respirations are somewhat quick and superficial. The temperature of the 
entire surface of the body is low, but the deep rectal temperature is high, 
39.4°, 40°, or 40.5° C. (103°, 104°, or 105° F.). The thirst is great and 
is a very prominent symptom. The fontanelle very soon becomes depressed. 
The urine is suppressed, and nervous symptoms, such as twitching of the 
arms and great restlessness, are present. Rapid emaciation takes place, and 
all the symptoms increase in severity. At first the infant whimpers, but 
soon it becomes listless, falls into a stupor, or may have convulsions. The 



886 PEDIATRICS. 

infant may die in this stage, which closely resembles the algid stage of 
cholera Asiatica. The disease appears to be self-limited, and if the infant 
survives the first two or three days a crisis comes, the skin becomes less 
cool and of a better color, the vomiting and diarrhoea grow less frequent, 
and finally it is left with a slight amount of simple diarrhoea and occasional 
vomiting. These symptoms may become chronic, in which case the infant 
finally dies of exhaustion or from an attack of one of the other gastro- 
enteric diseases, to which it is left very susceptible. 

Diagnosis. — The diagnosis of cholera infantum is not difficult if the 
characteristic symptoms are borne in mind ; these are rapid onset, constant 
vomiting, frequent serous discharges, intense thirst, high rectal temperature, 
low surface temperature, collapse, depressed fontanelle, sudden loss of 
weight, and distressed, restless expression, suggesting speedy death, all 
developing in from twenty- four to forty-eight hours. 

Prognosis. — The prognosis is bad. The more violent the attack, the 
higher the temperature, the less the vitality, and the warmer the weather, 
the worse is the prognosis. When the infant has survived the very acute 
symptoms which appear in the first two or three days, the prognosis is much 
more favorable. 

Treatment. — Cholera infantum is so formidable in its attack that it 
must be treated most energetically if we hope to succeed in saving the 
infant's life. The indications for treatment are (1) to assist the effort which 
nature is making to free the stomach and intestine from the poison which 
is in them ; (2) to restore the surface circulation, which is so seriously 
interfered with ; (3) to supply water to the tissues, which are being drained 
to so grave an extent ; and (4) to support the strength until the disease 
has run its course. 

The poison seems to act with especial virulence on those portions of 
the economy where it is most concentrated, — namely, the stomach and the 
intestine. We therefore have at first extreme irritation of these parts, 
which causes increased peristalsis, and later vaso-motor paralysis, with great 
transudation of serum. This condition of the gastro-enteric tract is to be 
especially borne in mind during the whole course of our treatment. 

In this disease we should not attempt to use any remedy which works 
slowly. The condition of the mucous membrane is in all probability such 
that absorption of drugs does not take place readily. The administration 
of drugs is, therefore, contra-indicated, for they may later, when absorption 
is being restored, prove fatal by their cumulative action. During the acute 
stage of the disease the digestive functions fail to act, and therefore food 
of any kind will be only an additional source of irritation. 

Early in the attack, and when the vomiting has not caused much pros- 
tration, the stomach should be thoroughly washed out with warm water and 
the intestine should be irrigated. If the rectal temperature is very, high, 
ice-cold water may be used for irrigation. Where the vomiting has con- 
tinued for some time and there is prostration with great thirst, the infant 



DISEASES OF THE INTESTINE. 887 

should be allowed to suck sterilized ice-cold water from the bottle. At first 
nothing else should be given by the mouth. 

The infant should be placed at once in a warm pack. This should be 
done by wrapping it to the chin in sheets wrung out of water at least as hot 
as 38° C. (100.4° F.). It should then be enveloped in a hot blanket. 
This procedure should be repeated as often as the infant shows signs of 
collapse or much cyanosis and coldness of the skin. This is the best 
method that I know of to restore the surface circulation. In extreme cases 
the subcutaneous injection of salt solution can be tried. 

While the infant is in the hot pack, water can be given freely by the 
mouth, and, if necessary, small and frequently repeated doses of stimulants, 
unless they appear to excite vomiting, in which case they should be given 
hypodermically . 

If the vomiting and diarrhoea still continue excessive after this treat- 
ment, small doses of morphine, 0.0006 gramme (yto" g^^^^)? ^^^ atropine, 
0.00008 gramme (-g^ grain), for an infant a year old, can be tried hypo- 
dermically. The effect should be carefully watched, and the dose repeated 
if necessary, as recommended by Holt. 

If, after the vomiting and diarrhoea have ceased, the heart'-s action con- 
tinues very weak and does not respond to stimulants, small doses of digi- 
talis should be given. The greatest caution should be employed in using 
drugs, however, as they generally do more harm than good. 

If an absolutely fresh and sterile milk can be obtained, it can be used 
as a food, as in any of the other forms of gastro-enteric diseases which I 
have already described, but for some days the percentages of the elements 
in the milk must be much lessened, and the child's strength must be sup- 
ported mostly by stimulants freely diluted with sterilized water. 

Cholera Asiatica. — Cholera Asiatica is a highly infectious disease, 
caused by the comma bacillus of Koch, which manifests its most violent 
symptoms in the gastro-enteric tract. Its symptoms very closely resemble 
those of cholera infantum. The disease in infants should be diagnos- 
ticated from cholera infantum, which is done by finding the comma 
bacillus in the vomitus or in the discharges. There are no especial dif- 
ferences between cholera Asiatica in the adult and the same disease in the 
infant. It is exceedingly fatal during infancy and childhood, and young 
infants who are attacked by the disease during a cholera epidemic seldom 
live. The treatment is the same as that which I have just described for 
cholera infantum. 

New Growths. — New growths in the enteric tract are very rare in 
infancy and childhood, and are mostly confined to myxomatous polypi of 
the rectum. 

Inflammatory. — The inflammatory diseases of the enteric tract may 
be aeide or chronic. 

Under acute inflammatory diseases may be included appendicith and 
ileo-colitis. 



888 PEDIATRICS. 

Appendicitis. — Inflammation of the appendix cseci is essentially a sur- 
gical disease, and is one which under all circumstances should be placed 
immediately in the hands of those who are skilled in abdominal surgery. 
From my observation of this disease I am so strongly impressed w^ith this 
fact that I consider an extended description of it in medical lectures and 
by physicians out of place. I shall therefore confine my remarks on this 
disease to a very few words, which will aid you in making a diagnosis when 
you meet with one of these cases. 

Under the term appendicitis we now include those inflammatory condi- 
tions in the neighborhood of the caecum which Avere formerly called csecitis 
and perityphlitis. The reason for this is that there is little doubt that in 
most instances the appendix is the part primarily involved. The disease 
occurs most commonly after the tenth year, and is rare in the early months 
of life, but it may occur at any age. 

Etiology. — The cause of appendicitis is in most cases an inflammation 
of the lining mucous membrane of the appendix arising from faecal concre- 
tions. It is seldom caused by any foreign bodies, such as seeds of any size. 

I have here a specimen of the appendix (Fig. Ill) which was taken 
from a girl nine years old forty -eight hours from the beginning of the 
attack, the first she had ever had. The operation was performed by Dr. 
S. J. Mixter, and was followed by complete recovery. 

Fig. 111. 




Appendix removed from female 9 years old. (Natural size.) 

On opening the appendix this faecal concretion was found (Fig. 112). 

Fig. 112. 



Fsecal concretion in appendix. (Natural size.) 

Pathology. — The pathological lesions which occur in these cases vary 
from a simple inflammatory condition, with exudation, induration, and thick- 
ening, to gangrene and necrosis. 

Symptoms. — The symptoms of appendicitis are, as a rule, the more 
obscure the younger the individual. In infants and young children ab- 
dominal pain may be difficult to localize, and may be referred to some other 
]3art of the body. In like manner pain in the thorax may be referred to 
the abdomen, so that it is often impossible to be guided by the apparent seat 



DISEASES OF THE INTESTINE. 889 

of the pain. There are no prodromal symptoms which are especially char- 
acteristic or of much aid in determining whether appendicitis is present. 
The temperature is often very misleading. I have seen a child with a 
severe attack of appendicitis in whom the acute symptoms disappeared in 
a few hours and the temperature was raised very little above normal. 
Dr. Mixter, whose surgical knowledge was called upon to determine what 
should be done in this case, decided to operate, and on opening the abdomen 
the appendix was found in a highly inflamed condition : pus had formed 
and distended it, and perforation had almost taken place. There is nothing 
especially significant in the pulse or the respiration which will aid you in 
diagnosticating the disease. In a number of cases, however, vomiting, 
pain and tenderness in the region of the caecum, and later a sensation of 
resistance and dulness on percussion, constitute a group of symptoms which 
should lead us strongly to suspect the presence of this disease. The vomit- 
ing, as a rule, is not stereo raceo us, and in young infants diarrhoea is apt to 
occur as often as constipation. 

In cases of appendicitis which recover after operation various inflamma- 
tory lesions are left, and the disease is liable to recur from time to time. 
This condition is known as chronic appendicitis. Where the symptoms 
continually recur, the patients lose in weight and strength, but often can be 
entirely cured by having the appendix removed. 

Diagnosis. — The diagnosis is to be made chiefly from intussusception 
and volvulus, especially the former. In intussusception, as I have already 
told you, there is usually an absence in the beginning of pain and tender- 
ness, and the tumor which is ordinarily found is to the left of the median 
line rather than to the right. The vomiting in appendicitis is not stercora- 
ceous ; in intussusception it is often so. Pain and tenderness to a varying 
degree are always present, but the tumor is often not felt until late in the 
disease. The temperature and pulse are generally slightly raised. The 
same anxious expression of the face occurs in appendicitis as in intussus- 
ception. You must not depend upon the locality of the tumor and the pain 
and tenderness in difierentiating these two diseases, for in some instances 
the inflamed appendix may be found to the left of the median line, and in 
intussusception, especially if not of the ileo-csecal variety, it may be on the 
right of the median line. All these questions, however, are for the skilled 
surgeon to decide ; and Avhen this group of symptoms is present we are 
justified in making a provisional diagnosis of appendicitis and in at once 
summoning surgical aid. 

Prognosis. — The prognosis of appendicitis under judicious treatment, 
especially if operative interference is instituted early, is very favorable ; but 
when operation has been deferred until perforation has taken place the 
prognosis becomes unfavorable. Even under these conditions, however, 
many cases recover. The prognosis of cases which are operat(\l upon when 
inflammation is not present between recurrent attacks of appendicitis is in 
almost every instance favorable. 



890 



PEDIATRICS. 



Treatment. — When you have made the diagnosis of appendicitis, you 
should at once place the child in bed, enforce absolute quiet, apply hot 
fomentations to the abdomen, and, if necessary, give sufficient opium to 
relieve the acute pain. Cathartics and laxatives should not be given. The 
food should be small quantities of peptonized milk, and should be given by 
enemata. It is almost needless to repeat that the best surgical aid should 
be called in at once to determine upon the next steps in the treatment. 

I have to report to you a case of appendicitis which was under the care 
of Dr. Crocker and was operated upon by Dr. George Haven. 

A child (Case 426), twenty-eight months old, had loss of appetite, sleeplessness, 
nausea, vomiting, slight diarrhoea, and abdominal pain. Two days before the operation a 
tumor had been found in the left lower part of the abdomen. The child's face had a 
pinched expression and showed much pallor. Her pulse was 170, her temperature 39.7° 
C, (103.5° F.). On the day when the operation was performed, in addition to the tumor 
which had first been found, the right half of the abdomen was filled by a tumor of some- 
what irregular outline, with tense walls, and giving an absolutely flat note on percussion. 
Changes of posture produced no effect on the physical signs. An incision was made 
through the middle of the tumor, and about a pint of pus escaped, together with masses 
of detritus having a strongly faecal odor. The child recovered entirely. 

I happen to have here in the wards a little girl (Case 427), eight years old, who illus- 
trates one of the mild cases of appendicitis which often recover without operation, and 
whom I have placed under surgical supervision in accordance with my strong opinions on 
this subject. 

Case 427. 




Appendicitis. Female, 8 years old. 

This child was well until four days ago, when she began to have severe pain in the 
right side in the region of the appendix. This was followed by headache, nausea, and 
vomiting. Marked tenderness soon appeared in the area where she complained of pain. 
The pain continued with slight intervals. The bowels were constipated. At first there 
was an almost constant desire to have a movement of the bowels. On entering the hospital 
the abdomen was tympanitic and not tender, except in the area which I have marked in 
black, which covers a space of 6.5 to 7.8 cm. (2 J to 3 inches). "Within this line there 
have been pain, tenderness, and dulness on percussion. Her tongue has been coated. On 



DISEASES OF THE IXTESTIXE. 891 

close inspection you will notice that there is slight bulging in the area marked in black. 
The temperature has been about 39.4° C. (103° F.), the pulse 100, the respirations 28. 

"With symptoms of this nature there is not much doubt that we are dealing with a case 
of appendicitis. Morphine, 0.004 gramme (Jg- grain), was required a number of times to 
relieve the pain. 

(Subsequent history.) On the day following the child's entrance to the hospital the 
temperature began to fall, the tumor became less distinct, and there was less tenderness and 
not much pain. It was decided not to operate, but to watch the case carefully. On the 
third day after entering the hospital, the seventh day of the disease, the temperature became 
normal, the pain and tenderness disappeared entirely, and the tumor became indistinct. 
The bowels moved naturally on the seventh day, and in the third week from the onset of 
the attack the child was perfectly well, and only a little resistance could be felt in the area 
which had been occupied by the tumor. 

Ileo-Colitis. — Under the term ileo-colitis are included all the more 
marked and grave lesions of the intestine. These lesions are so varied 
that it would be impossible to classify them in detail, and practicallv we can 
divide them in only a very general way. 

The divisions which have been adopted to simplify the subject are (1) 
simple catarrhal inflammation, which includes the non-ulcerative form of 
follicular inflammation, (2) follicular ulceration, (3) an inflammation charac- 
terized by a pseudo-membrane, (4) an inflammation caused by the typhoid 
bacillus, (5) an inflammation caused by the amoeba coli, and (6) an inflam- 
mation caused by the bacillus tuberculosis. The first three of these 
divisions, catarrhal, ulcerative, and membranous, although differing essen- 
tially in their prognosis, are so often represented by the same symptoms 
that they can be differentiated only in the most general way. A symptom 
common to all these diseases is that the temperature, although not neces- 
sarily high, is, as a rule, raised through the whole course of the disease. 
In this way we can usually differentiate these diseases from the non-inflam- 
matory conditions of which I have already spoken. There are so many 
varieties of pathological lesions found in connection with the catarrhal and 
non-ulcerative follicular and the ulcerative follicular inflammations that the 
clinical distinction between the two conditions, until our knowledge of these 
diseases shall have been greatly increased, must be very limited. In both 
the lesions are so varied that they probably arise from a number of organ- 
isms, and their pathology must for the present include all forms which 
cannot be classed under the pseudo-membranous, typhoidal, or amo?bic 
forms of ileo-colitis. They may occur as acute primary diseases, but are 
usually secondary to the fermental diarrhoeas, and sometimes to the infec- 
tious diseases, especially measles. 

In the pseudo-membranous form of ileo-colitis the ileum and the colon 
are chiefly affected. The lesions are probably due to a number of organisms, 
but its pathology is more definitely known than that of the catarrhal and 
ulcerative follicular forms. It is characterized by the presence of a mem- 
brane on the surface of the mucous membrane, which extends into it, due to 
a combination of fibrinous exudation and necrosis. That is, there is a defi- 
nite pathology. The disease may be primary or secondary. In the primary 



892 



PEDIATRICS. 



form it represents what is usually spoken of as epidemic or sporadic dysen- 
tery. The secondary form is that which follows certain infectious diseases, 
such as measles. All these forms are commonly spoken of as dysentery ; 
but from what I have told you you will see that the word dysentery should 
no longer be retained in our nomenclature, as it has been used for so many 
different pathological conditions. 

Before endeavoring to tell you what little is known regarding the 
symptoms of these diseases, I shall show you a few specimens illustrating 
some of the pathological conditions which occur in ileo-coUtis catan-halis, 
ileo-colifis ulcerafiva foIUcuIaris, and ileo-colitis pseudo-memhranosa. Much 
more extended studies of these conditions, both as to their pathology and 
their bacteriology, must be made before anything more than this general 
view of the subject can be used for clinical purposes. You will of course 
understand that these specimens which I am about to show you do not 
represent all the lesions which occur in these diseases, but illustrate some 
of the principal ones only. The notes in connection with these cases show 
how with our present knowledge it is usually impossible for us to diagnos- 
ticate the lesions during life. 

Fig. 113. 




Hyperplasia of the lymph-follicles. Waxren Museum, Harvard University. 

This first specimen (Fig. 113) is a portion of the colon of an infant who 
during life had only a slight diarrhoea. 



Case 428. Fig. 114. 




Non-ulcerative follicular inflammation. Simple hyperplasia of lymph-follicles. 
Female, 3 years old. Warren Museum, Harvard University. (Page 893.) 



Case 429. Fig. 115. 




Colitis follicularis non-ulcerativa. Male, 2 years old. 
and Surgeons, New York. 



Museum of the College of Physicians- 
(Page 893.) 



Case 429. Fig. 115. 
II. 




Colitis folliculiiris noii-ulcerativa. (Page 893.) 



Fig. 116 




Hyperplasia vf lymph-follicles (solitary glands). Muc. Mem., mucous membrane ; Lym. Ts. 
lymph-tissues; Mus., muscle; Fol., follicles. (Page 893.) 



Fig. ir 



^JfThi,: 



-f'!^^^^^ 



Muc. Mem 




Muc. Mem., mucous membrane ; Fol., follicles ; Submuc, submucous tissue ; Mus., muscle. 

(Page 893.) 



Case 430. Fig. 118. 




Ileo-colitis ulcerativa follieularis. Infant, 16 months old. ^Museum of the College of Physicians 
and Surgeons, New York. (Page 893.) 



Case 431. Fig. 119. 




Acute ulcerative catarrhal colitis. Female, 3 months old. Museum of the College of Physicians 
and Surgeons, New York. (Page 894.) 



DISEASES OF THE INTESTINE. 893 

You see that the lesion is quite marked and simulates closely the hyper- 
plasia of Peyer's patches which is commonly ^ en in typhoid fever ; but in 
this case it represents merely intestinal irritation. 

This next specimen (Fig. 114) was found at the autopsy of a little girl, 
three years old, who had been under the care of Dr. AVebber. 

The child (Case 428) was attacked with excessive vomiting after eating 
pigs' feet, and the vomiting continued until her death, five days later. The 
lesions are chiefly in the upper part of the colon, and consist of a general 
non-ulcerative follicular inflammation. The hyperplasia of Peyer's patches 
is, as you see, extreme. 

Through the kindness of Professor ^Y. P. Xorthrup I am enabled to 
show you some interesting specimens of lesions of colitis which occurred in 
his practice, and which are now preserved in the Museum of the College of 
Physicians and Surgeons, New York. 

This specimen (Fig. 115) is one of acute catarrhal follicular inflamma- 
tion without ulceration. 

The infant, a male (Case 429), two years old, entered Professor Northrup's service 
with a history of diarrhoea and general debility lasting two weeks. While the infant 
was in the hospital there was a continued high temperature, which at one time reached 
40° C. (104° F.). The symptoms were mostly of a cerebral type, and the abdominal symp- 
toms were not severe or prominent enough to indicate the marked lesions which were found 
at the autopsy. The post-mortem examination, made by Professor jN'orthrup, showed the 
following conditions : 

Brain normal. 

Stomach congested. 

The small intestine contained a large amount of thick mucus. The solitary follicles 
were enlarged, rather more in the upper third of the intestine. Peyer's patches were 
markedly swollen, and a few solitary follicles appeared to be ulcerated. The mesenteric 
lymph-glands were enlarged. 

The mucous membrane of the colon was swollen : the follicles were enlarged and some- 
what pigmented, but not ulcerated. 

Here is another portion of the colon (Fig. 115, II.) taken from the same 
infant (Case 429). 

As you see, the solitary follicles are very much enlarged, and in Peyer's 
patches, which are in the middle of the specimen, the hyperplasia is of a 
very high degree. 

I have also here some microscopic sections of this form of follicular 
inflammation. In this first specimen (Fig. 116) you will see the great 
enlargement of the lymph-follicles. 

In this next specimen (Fig. 117) you will notice the inflamed condition 
of the mucous membrane as well as the enlarged lymph-follicles. 

This next specimen (Fig. 118) was taken from an infant (Case 430) six- 
teen months old. 

The infant before entering the hospital had had occasional attacks of diarrhoea for 
three months, presumably caused by improper feeding Soon after entering the hospital it 
rapidly grew worse and died. 



894 PEDIATRICS. 

The autopsy, made by Dr. Northrup, gave the following results. No tubercular 
lesions. Bronchial lymph-follicles enlarged. Small intestine showed much swelling and 
congestion of Peyer's patches, but no ulceration. The colon showed extensive follicular 
ulcerations. In the small intestine and the colon were found masses and strings of greenish 
mucus ; no blood. 

This next specimen (Fig. 119) was taken from a female infant (Case 
431), three months old. 

The infant on entering the hospital was somewhat rhachitic, emaciated, and fretful. 
There were no vomiting and no fever. It took very little nourishment, and at this time 
was having one large, watery, faecal discharge daily. The faecal movements were green- 
ish yellow. The infant apparently improved for about a week. The temperature 
was then found to have risen, and during the next week it varied from 36.6° to 37.7° C. 
(98° to 100° F.). During the next week the temperature was sometimes subnormal. At 
the end of three weeks the infant began to fail rapidly without any discoverable cause, 
and died suddenly. 

The autopsy was made by Professor Northrup, and showed the following lesions : the 
mucous membrane of the ileum was swollen, and the lymph-follicles were enlarged, but 
not ulcerated. 

The report of the examination of the colon, made by Professor Delafield, was as fol- 
lows. Numerous ulcers, some round and some irregular in shape ; an increased production 
of mucus ; a profuse growth of connective tissue between the tubules, with disappearance 
of the tubules ; necrosis of the new tissue so as to form ulcers ; the solitary follicles swollen, 
but not concerned in the formation of ulcers, which are simply necrotic. No amoebae 
found. The process is one which would ordinarily come under the head of acute catarrhal 
colitis. 

The next specimen (Fig. 120) is one which I am enabled to show you 
through the kindness of Professor Holt. 

The infant (Case 432) was three months old, and was in the hospital under the care of 
Dr. Holt. It had no acute symptoms, but had never been well, and before entering the 
hospital had lost in weight and strength. It entered the hospital for vomiting and diarrhoea. 
Nothing was found on physical examination. While in the hospital it had from six to 
eight loose greenish discharges in the twenty-four hours, and vomited occasionally. Its 
temperature varied from 37.2° to 38.3° C. (99° to 101° F.). It gradually failed, and died 
twelve days after entering the hospital. 

The post-mortem examination, as you see (Fig. 120), shows extensive follicular ulcera- 
tion of the colon, especially in the lower part of the specimen, where there is a large ulcer. 
The tissues around the follicles are also involved, and the process has gone on to necrosis. 

This next specimen (Fig. 121) was taken from a male infant (Case 433) 
six months old, also a patient of Dr. Northrup's. 

The infant when it entered the hospital was in a very wasted condition, and died in a 
few days without any especial abdominal symptoms. 

The autopsy, made by Dr. Northrup, showed numerous superficial abscesses on the 
body, a general bronchitis, and a beginning broncho-pneumonia. The lesions in the in- 
testine were an inflammation of the solitary follicles of the ileum and of the colon, with 
small ulcerations at the apices of the follicles in the colon, no ulcers being present in the 
ileum. In the specimen these ulcers are, as you see, pigmented, which denotes a chronic 
condition. 

The apices of the follicles are sometimes found pigmented as the result of post-mortem 
changes, and may simulate these ulcerations. 



Case 432. Fig. 120. 




Inflammation of follicles and surrounding parts of colon. The process has gone on to necrosis. Female, 
3 months old. Warren Museum, Harvard University. (Page 894.) 



Case 433. Fig. 121. 




College of Physicians and Surgeons, New York. (Fage »y4.) 



Case 434 Fig. 122. 




Pseudo-membranous colitis. Child, 3>^ years old. Museum of the College of Phybicians and 
Surgeons, New York. (Page 895.) 



Case 485. Fig. 123. 





Pseudo-membranous colitis. Female, 4 years old. Ps. M., pseudo-membrane ; M. M., mucous 
membrane ; Subm., submucosa; Mus.. muscle ; Per., peritoneum. (Page 895.) 



Case 436. Fig. 124. 



NecMlic Mem 
inf. Muc. Mem. 




Mus 
5ubmuc. / 



Nee. Muc. Mem., necrotic mucous irieinbrane ; Inf. Muc. Mem., inflamed mucous membrane 
Mus., muscle ; Submuc, submucosa. (Page 895.) 



DISEASES OF THE INTESTINE. 895 

The next specimen (Fig. 122) is one of pseudo-membranous colitis. 

This child (Case 434), three and a half years old, a patient of Dr. Northrup's, entered 
the hospital in a very reduced condition following an attack of whooping-cough. It was 
attacked with diphtheria, and during the ten days that it was suffering from this disease 
there was a slight amount of diarrhoea, but no pain and no tenesmus. 

The autopsy showed this pseudo-membranous inflammation through the whole length 
of the colon, most marked in the lower third. The other organs were normal. The 
microscopic examination of the colon confirmed the diagnosis of pseudo-membranous colitis. 

I have here a microscopic section (Fig. 123) of another case (Case 435) 
of pseudo-membranous colitis. 

This child, a female, four years old, was a patient of Professor Northrup's. It had 
always been delicate. It had pneumonia twice in its fourth year. Eight days before its 
death it was attacked with vomiting and diarrhoea. There was blood in the faecal dis- 
charges. The pulse was rapid. The loss of strength and the pallor were marked. The 
eyes were sunken, and the tongue was dry. On the last day of its life it became very 
feeble, and died in convulsions. Early in the disease the discharges were frequent. Later, 
they were from four to six daily, and were accompanied by tenesmus and tenderness of the 
abdomen. 

The autopsy showed that the mesenteric lymph-follicles were not much enlarged ; the 
follicles in the colon were slightly enlarged. The whole intestine was injected in patches, 
and contained faecal masses of a yellowish color. The large intestine was filled with large 
quantities of faeces of foul odor and colored by bismuth. The whole surface was rough, 
and did not look like a mucous membrane, but rather as though a thin layer of gelatin had 
been poured over it. This film could be pulled away with the forceps. The solitary fol- 
licles were enlarged. 

The microscopic section of this specimen shows a marked fibrino-purulent exudation, 
forming a membrane which characterizes the disease as pseudo-membranous colitis. 

I have also here to show you, through the kindness of Professor North- 
rup, an interesting specimen (Fig. 124) of an intestinal lesion in connection 
with the pseudo-membranous condition which you have just seen. 

This child (Case 436), three and a half years old, had whooping-cough. It was then 
attacked with diphtheria, and during the course of the disease the temperature was raised 
continuously, at times being as high as 40° C. (104° F.). During this attack it had diar- 
rhoea with blood in the discharges, but no pain or tenesmus and no other symptoms of 
colitis. 

The autopsy showed a broncho-pneumonia, and a normal condition of the stomach and 
small intestine. The colon showed an apparent exudation, which simulated that of a 
pseudo-membranous colitis so closely that before the microscopic examination was made it 
was supposed to be identical with the pathological lesions found in the case of pseudo- 
membranous colitis (Case 435) which I have just shown you. The surface appearance in 
the fresh specimen was identical. Under the microscope, however, the lesion proved to be 
only a superficial necrosis of the mucosa, with swelling of the lymph-folliclos. 

This specimen should impress upon you how important it is not to rely upon the 
macroscopic appearances of intestinal lesions without microscopic corroboration. 

Now that you have seen these pathological lesions, you will understand 
why it is often impossible to differentiate them clinically from one another. 
I shall, therefore, speak of them together. 



896 PEDIATRICS. 

As illustrations of the difficulty and in many instances the impossibility 
of diagnosticating intestinal lesions I shall report to you some cases which 
have been under my care. 

One of these cases was that of a little girl (Case 437), five years old, who during the 
hot weather in August had been having a slight attack of fermental diarrhoea, which began 
with vomiting, headache, and a slight rise of temperature lasting a few hours. This was 
soon followed by four or five greenish-yellow discharges in the twenty-four hours, and a 
normal temperature. The diarrhoea diminished in two or three days, and the child seemed 
much better, but after a few days she was suddenly attacked with a temperature of 39.4° to 
40° C. (103° to 104° F.) and with frequent discharges of mucus and blood. She lost rapidly 
in weight, and looked very sick. After twenty-four hours, however, the movements 
became normal ; and on the following day, although left weak and prostrated, she seemed 
perfectly well, and had no return of the attack. During the acute symptoms it seemed as 
if she were attacked by one of the more severe forms of colitis, but the rapid recovery left 
the diagnosis very doubtful. 

The next case was that of a child (Case 438), seven years old, who entered my wards 
at the City Hospital with a history of having had a slight diarrhoea for a few days. The 
temperature was but slightly raised. The movements were infrequent, of a greenish-yellow 
color, and contained no blood or membrane, and scarcely any mucus. The child seemed 
fairly well on entering the hospital, but during the following few days became much ex- 
hausted. Although no other intestinal symptoms appeared, he sank rapidly, and died 
apparently from exhaustion. 

The autopsy showed extensive lesions of the whole colon, the mucous membrane was 
greatly thickened, and there were numerous ulcerations. 

The third case was that of a boy (Case 439), four years old, who was brought to the 
Children's Hospital for frequent vomiting following an attack of diphtheria. During the 
first three weeks that he was in the hospital the vomiting was the chief symptom. He 
was fed by nutritive enemata and improved in his general strength. Later, however, he 
became very much emaciated, the vomiting increased in frequency, and a few days before 
he died there was a slight diarrhoea. The temperature was normal or subnormal during the 
whole course of the disease. 

During the last four or five days the symptoms had pointed almost entirely to the 
stomach, but the post-mortem examination showed nothing abnormal in the stomach, lungs, 
heart, kidneys, or spleen. The mesenteric glands were swollen in the region of the ileo- 
csecal valve. The walls of the ileum and colon were thickened and reddened. There was 
a slight deposit of fibrin over part of the mucous membrane of the ileum. The lower 
35 cm. (13| inches) of the colon were found to be much thickened, the inner surface was 
of a dark-greenish color, and beneath it the tissue was deeply injected. The thickening 
seemed largely due to an exudation on the mucous membrane, which could not be torn 
away. The thickening ended quite sharply, but on some of the valvulae conniventes 
above a similar membranous deposit could be found. In the colon the thickening was 
most marked in the caecum and the rectum, and least so in the transverse colon, and the 
process seemed older than in the ileum. Cultures from the various organs were negative. 
Various organisms were found in the ileum, but none that seemed to be of especial sig- 
nificance. 

Etiology. — The etiology of these diseases I have already described 
under general etiology. 

Symptoms. — The symptoms of these forms of acute inflammatory ileo- 
colitis vary greatly, as a rule, but in a general way they can be recognized 
by a group of symptoms which differ from those of the non inflammatory 
diarrhoeas spoken of as fermental diarrhoea and cholera infantum. The 
best work which has been done on the symptomatology of these diseases 



DISEASES OF THE INTESTINE. 897 

is that by Holt, but we still find that the symptoms of these different 
forms of ileo-colitis are very unsatisfactory and unreliable for differential 
diagnosis. 

The onset of the disease may be preceded by a fermental diarrhoea, or it 
may be acute from the beginning and have prodromal symptoms of no 
more than a few hours. The temperature is elevated, the pulse is quickened, 
and the infant loses rapidly in weight and strength. The discharges are 
perhaps ten or twenty, or even more, in the twenty-four hours. Where the 
lesions are in the rectum there is tenesmus both before and after the dis- 
charge, and in the beginning of the attack an almost continuous desire to 
have a movement. The discharges contain fsecal matter at first, but soon 
become small, and consist of mucus, with sometimes pus, blood, and shreds 
of membrane. The odor may be very offensive, but when the mucus pre- 
dominates there is very little odor. The color and consistency are extremely 
variable, but generally the consistency is lessened and the color is a mix- 
ture of green, brown, and yellow. The blood is usually from congestion 
of the blood-vessels and straining, rather than from ulceration. Therefore 
we cannot determine from the presence of blood whether ulceration is pres- 
ent or not. At first the abdomen may be soft and not tender, but later in 
the disease it becomes distended, tympanitic, and somewhat tender, espe- 
cially along the course of the colon. Vomiting may occur at times. In 
severe cases the child is very restless, and there may be delirium and con- 
vulsions. The appetite is usually much lessened. The urine is nearly 
always lessened in quantity, is high-colored, and sometimes contains a 
small amount of albumin, especially when the temperature is high. Acute 
nephritis is, however, rare in these cases. Where there is much tenesmus 
and straining, and where the discharges are especially frequent, prolapse of 
the rectum may occur. The discharges often cause great irritation around 
the anus and on the buttocks. 

Diagnosis. — These forms of ileo-colitis are diagnosticated from the 
fermental diarrhoeas by the continued heightened temperature, the more 
frequent discharges, the small amount in each, the presence of blood or 
membrane, and the tenesmus. They may be differentiated from cholera 
infantum by the continuous and excessive vomiting and the serous dis- 
charges of the latter disease. 

Prognosis. — The prognosis of ileo-colitis, where ulceration has not 
occurred, is usually favorable, the duration of the disease being a few weeks. 
Some cases, however, are more severe, and sometimes prove fatal in a few 
days. Where there is ulceration, the prognosis is rather unfavorable. 
Where there is a diminution in the frequency of the discharges and faecal 
matter begins to reappear, and where the nervous symptoms and exhaustion 
lessen, the prognosis is good ; but where the symptoms increase in severity 
and the face looks pinched, where intractable vomiting arises and the nervous 
symptoms predominate, the prognosis is very unfavorable. 

The prognosis is less favorable where the ileo-colitis is complicated by 

67 



898 PEDIATRICS. 

broncho-pneumonia or tuberculosis. It is much influenced by the time of 
the year at which the attack takes place, the prognosis being worse if the 
disease occurs at a time when the convalescence is during a long heated 
period. The prognosis is also worse where the infants have to be treated in 
crowded cities and in the midst of unsanitary surroundings. 

Although there are no symptoms typical of the different forms of acute 
ileo-colitis, yet their clinical pictures differ somewhat. 

It is usually found in the simple catarrhal ileo-colitis, where ulceration 
has not taken place, that the symptoms are milder and that there is apt 
to be vomiting. These cases generally begin to improve in one or two 
weeks, and recover entirely in another week. An intestinal disturbance of 
a mild character may result, however, and prolong the disease. The chil- 
dren are usually a long time in regaining their strength, and relapses are 
quite common in this form if the diet is not carefully regulated. 

Sometimes, however, simple catarrhal ileo-colitis may be represented by 
symptoms of a very severe type, and it may run a rapid course, and end 
fatally. 

Where follicular ulceration has taken place the stomach is not apt to be 
much involved, the temperature is not, as a rule, high, and the course of the 
disease is rather slow, irregular, and prolonged. The infant fails steadily, 
and commonly dies. A remission in the symptoms and an improvement in 
the character of the fsecal discharges should lead us to infer that ulceration 
has not taken place. Where the inflammation is simply follicular, without 
ulceration, the cases are very apt to recover. 

Pseudo-membranous ileo-colitis is rare in infants, but when it occurs 
it is the most severe of all the forms. I have already stated that it is this 
form which is usually spoken of as epidemic or sporadic dysentery. The 
temperature is high,— 39.4°, 40°, or 40.5° C. (103°, 104°, or 105° F.). 
There are apt to be blood and membranous detritus in the discharges. 
The progress of the disease is usually rapid and without remission, and 
death may take place in a week or ten days. The nervous symptoms, such 
as restlessness and delirium, are quite prominent. The diagnosis of this 
class of cases, as I have just told you, can be made positively only by finding 
shreds of membrane in the discharges. 

Treatment. — The treatment of these forms of ileo-colitis should usually 
be in the beginning the same that I have already described for fermental 
diarrhoea. It may in this sense be spoken of as prophylactic, for in a large 
number of cases the organisms which produce ileo-colitis find a means of 
entrance through the irritated mucous membrane produced by a preceding 
fermental diarrhoea. Where the case is seen in its earlier stages, a mild 
laxative should be given, in order to clear away, as far as possible, the 
pathogenic organisms, which are present in large numbers. Small doses of 
castor oil act most efliciently, and can usually be given, especially to infants, 
without causing nausea or gastric irritation. 

In addition to this treatment by the mouth, thorough irrigation of the 



DISEASES OF THE INTESTINE. 899 

colon should be employed. This should be done twice in the twenty-four 
hours with warm sterilized water containing 3.75 grammes (1 drachm) of 
borate of sodium to the pint of water. One or two gallons of water should 
be allowed to flow in and out of the intestine at each irrigation. After the 
irrigation, small enemata of thin mucilage, about 120 c.c. (4 ounces), con- 
taining 15 c.c. (^ ounce) of bismuth in suspension, may be given once in 
three or four hours. 

According to the degree of pain, restlessness, and general discomfort, a 
slight amount of opium can be given in these injections, but in all cases 
this drug should be administered with great care ; one drop of tincture of 
opium in the first year, and two drops in the second year, once in five or 
six hours, will usually be sufficient to make the infant comfortable. The 
effect of the opium should be carefully watched, and the dose increased or 
decreased as is necessary. 

Where the tenesmus is extreme, it is well to use suppositories containing 
from 0.015 to 0.03 gramme (J to J grain) of cocaine. These supposi- 
tories will often give great relief if the painful lesions are mostly in the 
rectum, but where the lesions are higher in the colon they are not of much 
value. 

The use of antiseptics by the mouth I do not recommend. Bismuth 
can be given by the mouth with some advantage in these cases, but the dose 
must be considerable to accomplish good results. One-half drachm in the 
twenty-four hours should be given to a child a year old, and for older chil- 
dren the dose should be proportionately increased. Alcoholic stimulants 
can be given with benefit at all stages of the disease if there is evidence of 
a weakened heart, or if much exhaustion is present. 

A very limited amount of food of any kind should be given during the 
first twenty-four hours. Sterilized water containing an alcoholic stimulant 
and barley water had better be given at first, as it has been found that 
where a sterile liquid is taken by the mouth the number of bacteria in the 
intestine diminishes rapidly. When a perfectly fresh milk can be obtained 
it can be used, if sterilized and modified in its various elements so as to be 
adapted to the digestion of the especial case. A moderate percentage of fat 
and sugar, such as 3 and 5, and a proteid percentage of about 2, is a very 
good prescription to begin with. Weak broths can also be given. 

In some cases of ileo-colitis, after the acute symptoms have ceased the 
diarrhoea continues for many months and the disease becomes chronic. In 
these cases the temperature may be normal, and there is no especial pain or 
tenderness. The appetite often returns, but the cliild does not gain in 
weight, or it loses. The discharges are not so frequent as during the acute 
stage of the disease, varying from six or eight to two or three in the twenty- 
four hours. The discharges have a lessened consistency, and contain mucus 
and undigested food. There may at times be exacerbations of the symp- 
toms, and the children are very apt to die of some intercurrent disease. 

The treatment is change of air if possible, and otherwise is essentially 



900 PEDIATRICS. 

dietetic. The rules which I have already given you in speaking of the 
treatment of fermental cases are applicable also to this class of cases. 

The pathological conditions most commonly found in these chronic forms 
of ileo-colitis are great thickening of the muscular tissue, pigmentation of 
the mucous membrane, and very extensive ulceration. 

Amoebic Ileo-Colitis. — The next form of ileo-colitis which I shall speak 
of is the amoebic. It has its own definite anatomical lesions, which are 
usually in the colon. 

The disease is caused by a well-recognized organism, called the amoeba 
coll. It is very rare in northern climates, and is most frequently met with 
in tropical countries. A frequent source of infection by the amoeba coli is 
drinking-water. 

I have here a specimen (Plate III., Fig. c, facing page 112) from the 
intestine of a case of amoebic ileo-colitis. The large round bodies which 
you see lying in more or less clear spaces are the amoebae coli. The organ- 
ism can also be detected by directly examining the discharges under the 
microscope. 

The characteristic pathological lesion of this form of ileo-colitis is the 
peculiar, undermined condition of the edge of the ulcers and of the mucous 
membrane. The amoebae are found not only in the intestine, but also in 
the various organs, and with especial frequency in the liver. 

The disease is usually acute in its onset, but sometimes it may be 
gradual. The duration may be two or three months. 

There are no especial symptoms by which to distinguish this form of 
ileo-colitis from the others of which I have just spoken, and the only posi- 
tive proof of the existence of the disease is the presence of the amoebae in 
the discharges. 

The disease is rare in children, and the prognosis is very unfavorable. 

The treatment which has been followed by the most favorable results is, 
in addition to frequent and thorough irrigation of the intestine, injections 
of solutions of sulphate of quinine (1 to 5000). This treatment, however, 
aifects only the amoebae which are in the intestine, and not those which are 
embedded in the tissues. 

Typhoidal Ileo-Colitis (Typhoid Fever). — The typhoidal form of acute 
ileo-colitis is an infectious disease with a definite pathology, and is charac- 
terized by constant changes in the lymph-follicles, chiefly at the lower end 
of the ileum, in the mesenteric lymph-glands, and in the spleen. The dis- 
ease is produced by the bacillus of Eberth, which is constantly present in 
the lesions. Infection takes place largely through the gastro-enteric tract. 
The usual mode of conveyance into the body for the typhoid poison is in- 
fected milk or water. Typhoid fever is exceedingly rare in the first two 
years of life, is uncommon under three years, and after the third year be- 
comes more common as the child grows older. 

I have here a specimen (Fig. 125) of the bacillus of typhoid, showing 
its morphology. 



DISEASES OF THE INTESTINE. 901 

It is about three times as long as it is broad, and is about one-third as 
long as the diameter of a red blood-corpuscle. It is rounded at the ends. 

The pronounced pathological lesions, severe symptoms, and great vio- 
lence in type which are so characteristic of the typhoid fever of later years 
are so rare in infancy and early life that I shall confine myself in what I 
have to say concerning this disease to the conditions which it presents in 
the latter period. 

Fig. 125. 

Bacillus of typhoid. 

Pathology. — Although the more advanced and severe lesions of 
typhoid fever may occur in the early as well as in the later years of life, 
yet its characteristic lesions in young subjects are the milder and less severe 
pathological changes of the disease. These consist essentially of a hyper- 
plasia of the solitary lymph-follicles and Peyer's patches, and the process, 
instead of going on to ulceration, usually terminates in early resolution 
with fatty degeneration of the cells. Hemorrhage and perforation are there- 
fore rare complications in the typhoid fever of early life. There is, how- 
ever, nothing distinctive of typhoid fever in this hyperplasia of the lymph- 
follicles in children, for it is not uncommon to find this condition where 
death has occurred from other diseases of the intestine. It may also be 
present in such diseases as measles, diphtheria, and scarlet fever. Very 
marked hyperplasia of the lymph- follicles may be produced in children by 
irritating substances and by foreign bodies, not only food, but also drugs, 
such as turpeth mineral. I have, in fact, seen, at the post-mortem exami- 
nation of a child, marked enlargement of the lymph- follicles caused by 
doses of turpeth mineral given during life as an emetic. The pathological 
conditions in typhoid fever in the early years of life may be said to corre- 
spond to those which are met with in the aborted forms of the disease in 
later life. 

Symptoms. — The stage of incubation of the disease lasts from one to 
two weeks. The symptoms are, generally, not severe. The prodromal 
stage is usually short, young subjects having less power of resistance to the 



902 PEDIATRICS. 

poison than adults^ in whom the prodromal stage is often prolonged. As a 
rule, the temperature is moderate, but it may be high, as in adults, without, 
however, producing as severe symptoms, since children, commonly, are less 
affected by a high temperature than adults. 

The duration of the disease is generally much shorter than in adults. 
This short duration depends largely upon the mild form of the intestinal 
lesions, and usually shows that marked ulceration has not taken place. The 
temperature chart in this mild typical form of the disease is not apt to be 
so regular as where the lesions are pronounced. The temperature, al- 
though it returns to the normal by lysis, does not show so gradual a lysis as 
where marked lesions have occurred and where other sources of toxaemia 
have complicated the disease. The pulse is usually quickened in corre- 
spondence to the height of the temperature. The respirations are not espe- 
cially increased. The nervous symptoms so marked in later life are not 
prominent in early childhood. Headache slighter than that in adults may 
occur. Delirium, convulsions, and vomiting may be present. These 
symptoms, however, are not common. In some cases cerebral symptoms 
simulating somewhat those of meningitis arise, and are probably due to 
cerebral congestion or to toxic action. Aphasia occurs rather more fre- 
quently in young children than in adults. Its cause is not known, and it 
appears usually when the disease is declining. It may last for one or two 
weeks. 

The characteristic of typhoid fever in young children, as I have seen it, 
is apathy. The child takes the nourishment which is given to it, is not 
especially restless, and usually lies in a half-somnolent condition. As the 
disease progresses, it gradually returns to a more natural mental condition. 

Although it is probable that in most cases of typhoid fever there is some 
enlargement of the spleen, it is often impossible to detect this change by 
palpation, and percussion of the spleen in young children is well known to 
be very misleading. In some cases the rose-colored spots appear on the 
abdomen, but in quite a number I have been unable to detect them. There 
is apt to be a slight bronchial catarrh. The bowels are often constipated, 
though sometimes diarrhoea is present. The tongue is not so likely to be 
dry as in older subjects, and, although coated, it soon becomes clean at the 
tip and edges. The abdomen may be somewhat distended and tympanitic, 
but this symptom is often not marked, and pain and tenderness are rather 
infrequent. Epistaxis is rare in the typhoid fever of children. There is at 
times a slight albuminuria during the height of the fever, but a complicating 
nephritis is rare. 

Diagnosis. — During the first few days, typhoidal ileo-colitis may often 
be mistaken for various forms of febrile gastro-enteric disease. A num- 
ber of acute diseases, such as the exanthemata and pneumonia, may simu- 
late in their prodromal stages those cases of typhoid fever which begin 
with violent symptoms. The vomiting which occurs in the prodromal stage 
of typhoid fever may, in connection with the child's apathy, simulate the 



DISEASES OF THE INTESTINE. 903 

early stages of tubercular meningitis. It is therefore often impossible, in 
the early days of the disease, to make a positive diagnosis, and in some 
cases we are left in doubt as to the diagnosis for a week or ten days. 
The characteristic symptoms of the acute diseases already referred to, and 
of tubercular meningitis, will later be so apparent as to leave the diagnosis 
no longer doubtful. Jacobi lays stress on the probability of typhoid when 
there is a continuous high fever which is well borne by the infant, and 
when the intestinal symptoms are not violent. We should also remember 
that the differential diagnosis between the typhoidal form of ileo-colitis and 
malaria is at times, especially in children under two years of age, very 
difficult, and perhaps impossible, until the blood has been examined. Epi- 
demic influenza may in its onset simulate typhoid fever, but the period of 
doubt is very short. Acute miliary tuberculosis may in its typhoid type 
simulate typhoidal ileo-colitis very closely. Where, in the latter disease, 
the rose-colored spots do not appear, the delirium, distended abdomen, 
enlarged spleen, and even the irregular temperature, at times common to 
both diseases, may make the resemblance so close that the differential diag- 
nosis can not be made until the post-mortem examination. 

Prognosis. — The prognosis of typhoid fever in early childhood is good. 
The complications, whether arising from local disturbance of the intestjne 
or from cardiac and pulmonary disease, are rare in comparison with those 
met with in later life. You must remember, however, that the disease 
varies very much in its severity in different epidemics and in different indi- 
viduals, and that a child may have a severe type of typhoid fever and die 
from it. 

Treatment. — The treatment of the typical mild form of typhoid fever 
in young children is to keep the child in bed and to feed it regularly every 
two or three hours with fresh milk, modified according to the condition of 
its digestion, and heated to 75° C. (167° F.). As a rule, antipyretic drugs 
should not be used. The child should be bathed at least twice a day 
with water at a temperature of 32.2° C. (90° F.), not necessarily for the 
purpose of reducing the temperature, but as a hygienic measure. In most 
of the cases which I have seen this is all the treatment that has been found 
necessary from the beginning to the end of the disease. Where there are 
great restlessness and delirium, with a high temperature, 40.5° to 41° C. 
(105° to 106° F.), baths should be given once every three or four hours, but 
the temperature of the w^ater should not be below 26.6° to 29.4° C. (80° to 
85° F.), as this is usually sufficient to allay the symptoms. If the tem- 
perature remains high and there are symptoms of serious import, such as 
occur in the advanced stages of the adult type of typhoid fever, colder 
water can be used ; but, as a rule, it is not wise to employ water of a low 
temperature in children to the extent to which it has been found useful in 
adults. Alcoholic stimulants should be g^iven where there are sio^ns of 
exhaustion. 

The various complications which arise should be treated symptomatically. 



904 PEDIATRICS. 

The same care should be exercised during the convalescence of the child as 
in the advanced convalescence of the adult. 

I have here in the wards a case of typhoid fever. 

This child (Case 440), a boy, is five years old. 

Five days before entering the hospital he was taken sick with general malaise and 
fever. There had been no other symptoms, such as epistaxis or vomiting. On entering the 
hospital, an examination showed the tongue to have a thick brownish coat in the centre and 
a thin coat on the tip and edges. The child was in an apathetic condition. The pulse was 
rapid and regular. Nothing abnormal was found in the thorax. The abdomen was dis- 
tended and tympanitic, and showed one rose-colored spot. The spleen could be easily felt 



r 



Case 440. 



" 



^ 



% 



^i 



'^m^ 



Typhoidal ileo-colitis. Male, 5 years old. 

2.5 cm. (1 inch) below the border of the ribs, and on percussion the dulness reached as high 
as the seventh rib in the axillary line. I have marked this enlargement of the spleen and 
the lower border of the ribs in black. The upper border of the splenic dulness is marked 
by a broken line, and the figure 7 marks the seventh rib. The blood showed no leucocytosis. 
You see that the pupils react equally to light. You will also notice the apathetic expression 
of the child's face, and that he takes very little notice of anything. An examination of the 
urine shows the color to be normal, the reaction neutral, the specific gravity 1026, and that 
there is a slight trace of albumin. The sediment shows occasional hyaline and fine granular 
and fibrinous casts. 

(Subsequent history.) On the third day after entering the hospital, the eighth day of 
the disease, the child became very stupid, and sometimes delirious. There was a slight 
cough. 

On the twelfth day of the disease the child cried out at times, and was delirious. The 
skin was dry and hot. There were no more rose-colored spots. There seemed to be slight 
tenderness in the lower iliac fossa, but there was no gurgling. 

On the fifteenth day of the disease the temperature began to fall by lysis, and the child 
began to be fretful. 

On the eighteenth da}^ the temperature became normal. 

By the twenty-first day the child seemed bright, and was playing with its toys. The 
pulse was stronger. One week later it was sitting up in bed, and had a strong pulse and a 
good appetite. A few days afterwards it was up and about the ward, perfectly well. Here 
is the chart (Chart 31, page 905) from the fifth day of the child's illness until convales- 
cence was established on the twenty-fifth day. 



Case 441. Fig. 126. 




Typhoidal ileo-colitis, showing ulcers of colon. Female, 2 years old. 
U. S. Army Medical Museum. 



DISEASES OF THE INTESTINE. 



905 



Through the kindness of Dr. Billings I am enabled to show you this 
intestine (Fig. 126), which was taken from an infant with typhoidal ileo- 
colitis. 

CHAKT 31. 





Days of Disease. 


1 


F. 


5 


6 7 8 


9 llO 11 12 13 14 


15 


16 


17 18 19 20 21 22 23 24 25 


c. 


107° 
106° 
105° 
104° 
103° 
102° 
101° 
100° 
99° 

NORM-L 
TEMP. 

98° 
97° 
96° 
95° 

150 

140 

130 

120 

110 

100 

90 

80 

70 

60 

50 
45 
40 

35 
30 
25 
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41.1° 

40.5° 

40.0° 

39.4° 

38.8° 

38.3° 

37.7° 

37.2° 
37.0° 
36.6° 

36.1° 

35.5° 

35.0° 

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Typhoidal ileocolitis. Male, 5 years old. 



The infant (Case -l-il) was a patient of Dr. S. S. Adams, of AVasliinsxton. In this case 
the irregularity of the temperature curve and the prominent symptoms of cerebro-spinal 



906 



PEDIATRICS. 



irritation rendered the diagnosis so obscure that typhoid fever was not suspected until a few 
days before death. The post-mortem examination showed marked congestion of the entire 
brain, chiefly on the right side. The left hemisphere was covered with a gluey substance 
which filled the sulci and was especially abundant around the Sylvian fissure. The heart 
was normal. The lungs showed marked hypostatic congestion. The liver was normal. 
The gall-bladder was empty and pale. The spleen was enlarged. The kidneys were nor- 
mal. The stomach was congested. The mesenteric glands were enlarged and soft. The 
intestines contained a quantity of yellowish watery faeces. The lesions which you see in 
this specimen are in the ileo-colic portion of the intestine. You see that there is thickening 
and ulceration of Peyer's patches, and to a less extent of the solitary follicles. 



In order to impress upon you that in infants swelling of Peyer's patches 
and of the solitary follicles is not distinctive of typhoid fever, and that 
this condition frequently occurs from irritations of various kinds, I show 
you under this microscope (Fig. 127) a section taken from the intestine of 
a child. 

Fig. 127. 




Enlarged Peyer's patches closely simulating the lesions of typhoidal ileo-colitis. 
membrane ; Fol., enlarged follicles ; Mus., muscle. 



Muc. Mem., mucous 



The macroscopic appearances of this intestine so closely simulated the early stage of 
typhoid fever that cultures were made from it by Dr. Prudden to settle this question. No 
bacilli were found. This condition is often found in children in acute non-typhoidal ileo- 
colitis. 

Chronic Ileo-Colitis. — Under chronic ileo-colitis we include chronic 
appendicitis, those forms of ileo-colitis which follow acute attacks of ileo- 
colitis, and tubercular disease of the intestine. I have already spoken of 
chronic appendicitis and the chronic form following acute ileo-colitis, and 
shall, therefore, devote only a few words to intestinal tuberculosis. 

Tubercular Ileo-Colitis. — Tubercle of the intestine in infancy and 
childhood is quite common. The small intestine is most frequently in- 
volved. The disease may be primary in the intestine, but this is very 



Case 442. Fig. 128. 




Tubercular ulcers of colon. Female, 8H years old. Museum of the College of 
Physicians and Surgeons, New York. 



Case 443. Fig. 
I. 



129. 




Tubercular ulcer of small intestine. Female, 2% years old. Museum of the 
College of Physicians and Surgeons, New York. 



DISEASES OF THE IXTESTIXE. 907 

rare. At the Boston Children's Hospital I have had one case where the 
tubercular lesions were confined to the intestine and to the mesenteric 
glands. In this case Professor Coimcilman considered that the evidence 
was in favor of the intestinal tubercle antedating the tubercle of the glands. 
In the great majority of cases the tubercular ileo-colitis is secondary to 
tuberculosis elsewhere, and in such cases frecjuently follows tuberculosis 
of the mesenteric glands. 

PATHOLoaY. — According to Osier, the ulcers are situated chiefly in the 
ileum, and involve the solitary follicles and Peyer's patches. The tuber- 
cular ulcer has the following characteristics. In contradistinction to the 
tA^hoidal ulcer, the long diameter of which coincides with the long axis 
of the intestine, the tubercular ulcer is transverse to the long axis, rarely 
ovoid, and often irregular in outline. The edges overhang, and the base is 
infiltrated. 

Through the kindness of Professor Xorthrup, I have here some speci- 
mens of tubercular ulcers. This first specimen (Fig. 128, facing page 906) 
was taken from a female (Case 442) eight and one-half years old. 

This child, a patient of Dr. IS'orthrup's, was attacked, two months before her death, 
with chills, fever, and prostration. The temperature at first varied from 38.8° to 39.4° C. 
(102° to 103° ¥.), but as the disease progressed the temperature gradually fell. There 
was rapid emaciation. The abdomen was sunken at first, but later became tense. There 
were pain, tenderness, and resistance in the right inguinal region. The submaxillary, cervi- 
cal, and inguinal lymph-glands were enlarged. The urine contained albumin and hyaline 
casts. There was diarrhoea. The autopsy showed the lungs to be normal. The bronchial 
and retroperitoneal lymph-glands were enlarged and cheesy. The colon shows two large, 
sloughing ulcers, one in the region of the caecum and the other in the ascending portion. 
You see that they are transverse to the axis of the colon, and that their edges are over- 
hanging. The entire membrane is thickened, and there is some follicular ulceration. 

This next specimen (Fig. 129) was also taken from a patient of Dr. 
Northrup's. 

The child (Case 443), a female, two years and eight months old, had had diarrhoea 
occasionally for a year. It had also had convulsions. It died soon after entering the hos- 
pital. The autopsy showed these extensive ulcerations in the small intestine (I.) and this 
large ulcer in the ciecum (II., page 908). There were also tubercular ulcers in the middle 
third of the colon. 

The peritoneal surface showed miliary tubercles. The mesenteric and bronchial 
lymph-glands were markedly enlarged and cheesy. 

Symptoms. — The s^nnptoms of tubercular ileo-colitis are varied and 
rather indefinite. The most common symptom is a persistent diarrhQ?a. 
The diarrhoea does not, however, correspond to the extent of the lesions, as 
large ulcers may exist and constipation be present, especially if they are in 
the ileum. In cases of primary tubercle of the intestine the only sure means 
of determining the tubercular character of the disease is the finding of 
the bacillus tuberculosis in the discharges. Where the disease is secondarv 
to tuberculosis elsewhere, the tubercular involvement of the intestine mav 



908 



PEDIATRICS. 



be suspected when at any time during the course of the disease the infant 
is attacked with diarrhoea of an obstinate nature. In these cases the diag- 
nosis can also be established by finding the tubercle-bacilli in the discharges. 



Case 443. Fig. 129. 
II. 




Large tubercular ulcer of caecum. 

The prognosis is very unfavorable, and death may occur either from the 
severity of the intestinal symptoms or, as pointed out by Osier, more rarely 
by perforation or hemorrhage. 

ANIMAL PARASITES. — The animal parasites which are found in 
the intestines of infants and children are the same that occur in older sub- 
jects. The only ones, however, which are common and important enough 
to speak of are the oxyuris vermicularis (pin-worm), the ascaris lumbricoides 
(roundworm), the taenia solium, and the taenia mediocanellata. 

Oxyuris Vermicularis. — The oxyuris vermicularis is a minute worm 
which looks like a little piece of white thread. The female is from 0.6 to 
1.2 cm. (J to J inch) in length. The male is about one- third as large, and 
has the tail rolled into a spiral. 

I have here some of these worms to show you (Fig. 130). Their de- 



DISEASES OF THE INTESTINE. 909 

velopment takes place in the large intestine, and the mature worms deposit 
their e^rffs in the rectum. Thev enter the intestine throus^h the mouth, and 
children are very apt to reinfect themselves by carrying the eggs on the 
fino^ers or under the nails to their mouths. 

Fig. 130. 




Oxjnris vemiicularis. Ascaris lumbricoides. 

These worms sometimes exist in large numbers, ana their development 
is so rapid that it is often difficult to dislodge them completely. The most 
common symptom of the oxyuris is an intense itching about the anus. The 
sleep of the child is disturbed by this irritation, and various nervous symp- 
toms develop in children who are infested A^dth this parasite. Thus incon- 
tinence of urine sometimes results. In girls the parasite, by migrating 
from the anus to the vulva, may cause a vulvo- vaginitis. 

Diagnosis. — The diagnosis of the presence of these, as of other intes- 
tinal parasites, can be made only by finding the worm or its ova. Where 
they are suspected, an enema of clear water should be given. If the para- 
sites are present, they will be dislodged, and careful inspection will disclose 
their presence. Wherever there are symptoms of reflex irritation in the 
neio^hborhood of the anus or the s^enital organs, the oxvuris should be sus- 
pected and sought for. The parasites can often be found in the faecal dis- 



910 PEDIATRICS. 

charges, and in some cases they can be seen by simply stretching open the 
anus and examining the mucous membrane of the rectum. 

Treatment. — Although most of the worms are in the rectum, yet they 
also infest the upper parts of the intestine, and therefore cannot be reached 
by enemata. In many cases enemata of salt-and-water are sufficient to pro- 
duce a cure, but in some cases the salt, even in small amount, is so irritating 
that it cannot be used. Infusions of quassia may also be employed as ene- 
mata. One of the most effective methods of dislodging the parasite is to 
give every evening at bedtime an injection of 60 c.c. (2 ounces) of sweet oil. 
This is allowed to remain in the rectum for five or six minutes, and a large 
enema of water is then used to wash out the oil, which usually carries with 
it the parasites from the lower colon and the rectum. Care must be taken 
in regard to cleanliness, so as to prevent reinfection. 

Where this treatment is not sufficient, lozenges of santonin, 0.01 to 0.03 
gramme (J to J grain), according to the age, may be given two or three 
times daily. 

Every two or three days a cathartic, such as castor oil or calomel, should 
be given. Care must be used in giving santonin not to produce symptoms 
of poisoning, such as gastro-enteric irritation, dizziness, and yellow vision. 
This occurrence, however, will not be common if in each case you carefully 
watch the effect of the drug on the child. You must also bear in mind 
that serious symptoms, such as convulsions, have been caused by a lack of 
care in using this drug in young children. 

Under this treatment, aided by high rectal injections, the worms can in 
most instances be eradicated. I have, however, met with very intractable 
cases where months and even years had elapsed before treatment of any 
kind was successful. In such cases temporary relief can be obtained by 
giving the child each night, or two or three times a week, a small enema 
of oil. 

AscARis LuMBRicoiDES. — The ascaris lumbricoides is a long, cylindrical, 
yellowish-white or reddish-yellow worm, pointed at both extremities. The 
male is distinguished from the female by the fact that it is smaller and is 
always rolled upon itself, while the female is straight. The length of the 
male is from 10.4 to 18 cm. (4 to 7 inches), and that of the female from 
15.5 to 28.5 cm. (6 to 11 inches). 

Here are some specimens (Fig. 130, page 909) of lumbricoid worms. 
The larger worm is the female. The eggs of this worm are oval in shape, 
0.075 mm. long and 0.058 mm. wide. When they are first passed they are 
almost transparent, but they soon become yellowish and opaque. These 
eggs are not developed within the intestine, but may pass out with the faeces. 
They are very tenacious of life, and may develop under favorable circum- 
stances after many years. The embryos are developed outside of the body, 
and reach the intestine with the drinking-water, where they develop into the 
mature worm. 

The habitat of the worm is usually in the small intestine. It may, 



DISEASES OF THE INTESTI:N^E. 911 

however, pass through the rectum either with the fseces or alone, and may 
migrate into the stomach, oesophagus, or nose. Instantaneous death has re- 
sulted from the entrance of these worms into the air- passages. They may 
also at times enter the common and cystic bile-ducts, and they have even 
penetrated farther and caused abscess of the liver. There is no danger of 
their perforating a normal intestine, but where ulceration has been present 
perforation has occurred. 

Symptoms. — There are no especial symptoms produced by this worm, 
and we can diagnosticate its presence only by seeing it or by finding the 
eggs in the faecal discharges. The worm may in some instances produce a 
feeling of discomfort or even colic in the region of the umbilicus. Neither 
of these symptoms, however, can be depended upon, and an anthelmintic 
is required to determine whether the parasite is present. As a rule, the 
presence of these parasites in the intestine, imless in very large numbers, is 
not especially important. 

Treatment. — The most efficacious treatment of this form of parasite 
is with santonin, which should be given in the same doses and with the same 
caution as I have already described in speaking of the treatment of the 
oxyuris. 

In addition to santonin, the freshly prepared fluid extract of spigelia and 
senna, in doses of half a teaspoonful for a child two years old, and. a tea- 
spoonful for older children, can be given two or three times a day, care being 
taken not to produce too much irritation. The oil of chenopodium, three or 
four drops on sugar for a child two or three years old, and eight or ten 
drops for older children, can also be given. A cathartic should be used in 
connection with these drugs, as well as with santonin. 

T^xi^E (Tape-worms). — Two forms of tteniae occur in children. One 
of these is the taenia solium, the pork tape-worm. It has a slight projec- 
tion at the apex of its head, around which are a series of hooks, and below 
which are four sucking-disks. The other form is the taenia mediocanellata, 
the beef tape- worm. It has a blunter head than the t^nia solium, and does 
not have the circle of hooks. 

There is nothing especial to be said concerning these worms, and I 
refer to them merely because at times they occur in early life. They are 
never met with in nursing children when milk forms the exclusive diet. 
There are no especial symptoms produced by this worm, and the diagnosis 
is made entirely by finding the segments in the faeces. There is no especial 
danger to life from the presence of the tape-worm. 

I have here two specimens (Fig. 131, I., II., page 912) of taenia to 
show you. 

The worm in the bottle was from a child from whom the entire worm 
was expelled, and you can see, by means of a magnitying-glass, the head. 
The absence of hooks shows it to be the variety called taenia mediocanel- 
lata. I show you the other worm in order to impress upon you the impor- 
tance of obtaining the head. You see that the head is not present, and 



912 



PEDIATRICS. 



that it has evidently broken off near the extremity of the neck. In this 
case the head remained in the intestine and the worm grew to the usual 
length again. These worms vary in length from 605 to 1512.5 cm. (20 to 
50 feet). 

The treatment employed for expelling this worm is the same in children 
as in adults^ but we should be very careful not to irritate too much the 
sensitive gastro-enteric mucous membrane of the young child. The child 
should first be treated with laxatives, so as to free the intestine. Food 

Fig. 131. 




Taeniae. I., without head ; II., with head. 



should be withheld from the early evening until as late as possible the next 
day. An anthelmintic should then be given, followed in one or two hours 
by a cathartic. This usually results in the expulsion of a large mass of 
segments. Great care should be taken to prevent the head from breaking 
off before it is expelled. The anus should be carefully dilated during the 
expulsion of the worm. Sitting on a vessel of hot water seems to help to 
prevent the head from breaking off. 



DISEASES OF THE INTESTINE. 913 

There is no anthelmintic which I have found especially successful in 
expelling the taeniae. One of the most harmless is the alkaloid pelletierine 
from pomegranate. One-half teaspoonful of the tannate of pelletierine can 
be given to a child from three to five years old. As dizziness and headache 
are sometimes complained ofj it is well to have the child kept in bed and 
lying down until the effect of the anthelmintic has passed oif. The oleo- 
resin of male fern may also be used. The dose is 0.94 to 1.88 gramme 
(J to J drachm). The cathartic which is most useful in these cases is 
Epsom salt, 7.5 to 15 grammes (2 to 4 drachms). 

It is hardly worth while to mention the other numerous anthelmintics 
which have been recommended, as they are usually inefficient. 



58 



DIVISION XIV. 

DISEASES OF THE LIVER, PANCREAS, SPLEEN, 
AND PERITONEUM. 



IvKCTURK XIvVI. 

LIVER. — In infants and young children the liver is proportionately 
larger than in later life. In a previous lecture (Lecture lY., pages 121, 
122, 124) I have shown by percussion the size of the liver at different ages, 
and I shall therefore now merely refer you to what I said at that time. 

Icterus. — Icterus is a symptom of a number of diseases, as well as 
of disease of the liver, but it so commonly occurs where the liver is either 
directly or indirectly affected that it is best spoken of in connection with 
hepatic disease. The icterus which arises at birth, either of the temporary 
form, such as icterus neonatorum, or from obliteration of the bile-ducts, I 
have spoken of in a previous lecture (page 107). I have also spoken of 
icterus as a symptom when describing acute and chronic duodenal indiges- 
tion. You must not assume that there is necessarily hepatic disease because 
icterus is present, as any slight mechanical disturbance in the liver produced 
by diseased conditions elsewhere may cause icterus. In these cases, even 
though the liver may be somewhat enlarged, it is not a symptom of much 
import, and the liver is soon restored to its normal condition, provided that 
the original disease has disappeared or has ceased to produce hepatic dis- 
turbance. Icterus may also occur as a symptom in septic inflammation of 
the umbilical vein. In these cases the liver is apt to be enlarged and tender. 
Convulsions commonly occur. Yomiting, diarrhoea, abdominal swelling, 
pain, and tenderness are present. The temperature is high. The respira- 
tions are increased, and death usually occurs from exhaustion or from septic 
inflammation of the pleura, pericardium, or other parts. 

Diseases of the Liver. — Diseases of the liver are not common in 
infancy and childhood, as the inciting causes of hepatic disease are usually 
not present in early life. When hepatic disease occurs, it is commonly 
secondary to some general disease, and therefore it need not be dwelt upon 
at length in a separate lecture. 

The acquired pathological lesions which occur in the liver in infancy 
914 



DISEASES OF THE LIVER, PANCREAS, SPLEEN, AND PERITONEUM. 915 

and childhood do not differ from those which are met with in later life. A 
rapid increase and decrease in the size of the liver are not infrequently met 
with in disease, and careful measurements have shown that even a very 
slight disturbance of health may cause in young children a variation of 
from 2 to 4 cm. (f to 1 J inches) in the size of the liver. 

Acute Yellow Atrophy of the Liver. — It is uncommon for the 
liver to be decreased in size, but this occurs in the rare cases of acute yellow 
atrophy at times met with in children. The disease is insidious in its onset, 
and is characterized by general symptoms of malaise, with icterus and bile- 
stained urine. In the beginning of the disease the liver is enlarged, but in 
the later stages it is decidedly diminished. Cerebral symptoms and vomit- 
ing are quite prominent, and death invariably occurs. 

In most diseases which are accompanied by hepatic disturbance it is 
much more common to find the liver enlarged than to find it diminished in 
size. This enlargement may occur from a number of causes, among which 
is mechanieal congestion, arising in the course of cardiac disease. I shall 
presently show you, when speaking of diseases of the heart, a case (Case 
503, page 1042) illustrating this form of enlargement. 

The morbid conditions of the liver which are most commonly met with 
are fatty infiltration, amyloid infiltration, tuberculosis, and interstitial hepatitis. 
This latter form of hepatic disease may arise under various pathological 
conditions. Thus, it is a frequent lesion in syphilis, and may occur in a 
number of systemic diseases. It may also result from the use of alcohol, 
and at times it occurs apparently unassociated with disease of any other 
organ. 

Other pathological conditions of the liver, such as hepatic abscess, para- 
sites, such as hydatids, and new growths, such as carcinoma, adenoma, and, 
as occurred in a case at the Boston Infant Hospital, sarcoma, are too rare to 
be considered in a general clinical lecture on children. 

Fatty Infiltration of the Liver. — Fatty liver in early life does 
not differ pathologically from that which is met with at a later period. 
The liver may or may not be enlarged, and there are no especial hepatic 
symptoms which characterize this condition, the symptoms being those 
of the general disease from which the child is suffering. It may be found 
associated with a number of diseases, especially rhachitis and tuberculosis. 
When the liver is enlarged from this cause its surface is found to be smooth 
and palpation is painless. 

The prognosis, unless the disease is dependent upon some incurable dis- 
ease elsewhere, is fairly good. 

The treatment is essentially dietetic and hygienic. 

Tuberculosis of the Liver. — Tuberculosis of the liver occurs in 
connection with general tubercular disease of other organs, and does not in 
itself present any especially characteristic clinical manifestations. The dis- 
ease is commonly found in the form of miliary tubercles and cheesy nodules. 
Except in rare instances where large caseous masses cause obstruction and 



916 



PJEDIATEICS. 



later disintegration of the tissues, with hepatic enlargement and abscess, it is 
not usually recognized during life. 

Amyloid Liver. — When amyloid changes are present in the liver, 
other organs, such as the spleen, kidneys, and intestine, are involved. 
Amyloid infiltration may occur in the course of tuberculosis, where there is 
chronic disease of the bones, with extensive suppuration, and in wasting dis- 
eases. A very prominent symptom in this condition is extreme anaemia. 
The liver is, as a rule, very much enlarged, and commonly more so than in 
any of the other hepatic disturbances. Its surface is smooth, and there is 
rarely hepatic tenderness or pain. Ascites is rare, and there is usually no 
icterus. 

The diagnosis is not difficult if we find that the child has one of the 
diseases which I have just mentioned as being the causes of amyloid changes. 

When these changes occur in the liver the prognosis is very grave, and 
there is no treatment which will be of more than temporary benefit. The 
treatment, therefore, is simply symptomatic. 



This boy (Case 444) is seven and three-quarter years old. 

Case 444. 




Amyloid liver. Pulmonary tuberculosis. Male, *1% years old. 

There is no history of tuberculosis in his family. He had pertussis when he was one 
and a quarter years old, and measles when he was three years old. He seemed well and 
strong until seven months ago, when he became listless and began to have fever and to per- 
spire profusely. Four weeks ago he began to vomit occasionally, to complain of headache, 
and to cough. You see that although he has evidently lost in weight he is not especially 
emaciated. His entire skin is extremely pale and has a waxy look, which is apparently not 
due to jaundice. His mucous membranes show much anaemia. His tongue is heavily 
coated, and his breath is offensive. He is dull and apathetic. The cervical glands are 
enlarged and slightly tender, but do not fluctuate. The glands are moderately enlarged in 
the axillae and groins. The percussion of the right lung, especially at the apex, is dull, and 
there are numerous rales. The area of cardiac dulness is not enlarged, but there is a slight 
systolic murmur at the apex. The spleen is slightly enlarged. The edge of the liver can 



DISEASES OF THE LIVER, PAXCREAS, SPLEEJs', AND PERITONEUM. 917 

be felt below the line of the umbilicus. The area of hepatic dulness is increased, as is 
represented by this broken line. I have also indicated the lower part of the sternum and 
the lower borders of the ribs by black lines. There is no hepatic tenderness, and the child 
does not complain of pain. The lower part of the abdomen is dull on percussion as high 
as the line which I have drawn under the umbilicus. This is due to a slight amount of 
ascites. The legs are swollen. The urine has a specific gravity of 1010, and contains a 
slight trace of albumin, an occasional hyaline cast, and renal epithelium. The temperature 
has varied from 37.2° to 39.4° and 40.5° C. (99° to 103° and 105° F.). The increased 
size of the liver is probably due to amyloid infiltration. 

(Subsequent history.) A few days later the child grew rapidly weaker, and died of 
exhaustion. 

Interstitial Hepatitis (Cirrhosis). — The syphilitic form of hepatitis 
as it occurs in infancy I have ah-eady described in my lecture on Hereditarv 
Syphilis (page 489). 

Interstitial hepatitis as it occurs in childhood may be atrophic or hyper- 
trophic. The general symptomatology differs but little from that of the 
adult. In the beginning the symptoms are very apt to be confounded with 
those of simple congestion arising from digestive disturbances. There may 
be abdominal pain, slightly augmented by pressure. Diarrhoea and con- 
stipation alternate. There are usually ascites and slight jaundice, and at 
times dilatation of the subcutaneous abdominal veins. Stigmata composed 
of collections of dilated minute veins are sometimes observed on the face. 
The temperature is irregular. As a rule, it is not much heightened, and in 
fact is often subnormal. 

The prognosis and treatment in early childhood are the same as in adults. 
A certain number of cases seem to have followed scarlet fever and measles. 

Alcohol is sometimes an etiological factor in infancy and early childhood. 
Where the disease is caused by alcohol the pathological condition is, as a 
rule, atrophy. Enlargement is not common, and the symptoms are the 
same as in the adult, the ascites being especially prominent. 

Where the hepatitis is apparently not dependent on disease elsewhere, 
and is not due to alcohol, there are no characteristic symptoms beyond the 
eulargement of the liver. In this form the ascites is usually small in 
amount, and the diagnosis can be made only by eliminating the other forms 
of enlargement. 

I have here a case of hepatic enlargement which seems to represent 
clinically that form of hepatic disease which is commonly spoken of as 
hypertrophic cirrhosis. 

This little girl (Case 445, page 918) is eighteen months old. 

There is no history of syphilis or of tuberculosis. She had pertussis when she was ten 
months old, and the cough lasted for several months. She has never taken alcohol in any 
form. She was well until three months ago, when she began to complain of pain in the 
abdomen and to become pale. Two weeks before entering the hospital she had diarrhcva, 
and her abdomen was noticed to be swollen. On entering the hospital and being placed 
on a proper diet, the diarrhoea ceased, but the swelling of the abdomen increased. The 
child, as you see, is well developed, but pale. The abdomen is much enlarged. The edge 
of the liver can be felt nearlv as low as the line of the umbilicus. I have marked out the 



918 



PEDIATRICS. 



area of dulness on percussion with blacli lines. The lower one shows the notch between the 
right and the left lobe, which is distinct and easilj^ palpable. There is no especial tender- 
ness on pressure. The spleen is slightly enlarged. In the lower part of the abdomen there 
is a moderate amount of dulness and fluctuation, showing the presence of fluid. There are 
no glandular swellings. The heart is normal, but is pushed up somewhat by the abdomi- 
nal distention. I have indicated the cardiac area of dulness by a black line, and the lower 
border of the ribs and ensiform cartilage by a broken line. 

Case 445. 




Hypertrophic cirrhosis. Female, 18 months old. 

The child has improved in its general health since entering the hospital, and has a 
fair appetite, Physical examination shows the presence of no other disease. Without 
an autopsy, however, the diagnosis must necessarily be held in abeyance. 

(Subsequent history.) The child remained in the hospital for a few weeks, and im- 
proved in its general health so that it seemed quite bright. The ascites did not increase in 
amount, but the liver remained enlarged. The child was taken away from the hospital, 
and its subsequent history could not be obtained. 

PANCREAS. — Diseases of the pancreas are practically unknown in 
infancy and childhood, Avith the exception of the general tissue-changes 
which may be met with in syphilis, and which I have already described 
(page 490). New growths of a malignant nature have been reported. 

SPLEEN. — The spleen may be involved in tuberculosis, and may show 
amyloid changes in connection with other organs. 

It is frequently enlarged in the course of a number of diseases which I 
have described elsewhere. 

PERITONEUM. — Diseases of the peritoneum may be of non-inflamma- 
tory or inflammatory origin. 



DISEASES OF THE LIVER, PANCREAS, SPLEEN, AND PERITONEUM. 919 

The non-inflammatory diseases are mostly represented by new growths. 
These may be of a malignant nature, such as carcinoma and sarcoma, or 
they may be lipomata or of a cystic character. In this connection it is 
well to say that tumors of the omentum are rare, but that cysts and hyda- 
tids may occur in this region. 

The differential diagnosis of these various forms of peritoneal and 
omental growths can scarcely be made during life. 

The treatment is essentially surgical. 

The inflammatory diseases of the peritoneum are represented by peri- 
tonitis. 

Peritonitis. — Inflammation of the peritoneum may be acute or 
chronic, and is a condition of great importance in infancy and early life. 
Peritonitis may occur in the infant and child as it does in the adult. It is 
so rare in infancy and childhood as an idiopathic disease that the cases in 
which it has been studied post mortem have occurred almost exclusively 
during uterine life. Many of these, moreover, have presented a history of 
syphilitic infection. The septic form of peritonitis is not infrequently met 
with in the early weeks of life, and I have already referred to it when 
speaking of phlebitis umbilicalis (page 425). 

I have here an infant (Case 446) who was brought to the hospital yesterday to be 
relieved of extreme distention of the abdomen. 

Case 446. 




Probable ihtra-uterine x)eritonitis. Infant, 5 weeks old. 

The infant weighed at birth 4500 grammes (10 pounds), seemed strong, and nursed for 
three weeks. There is no history of syphilis or of tuberculosis. After birth it began to be 
icteric. It passed meconium, but the faecal movements since then have always been white. 
A few days after birth the abdomen began to swell, and it has since continued to increase in 
size. The skin is very tense, and the veins connected with the portal circulation stand out 
in marked relief all over the abdomen. The infant vomited once four days ago, and again 
this morning. It has become much emaciated. There is distinct fluctuation in every part 
of the abdomen, and dulness on percussion. An examination shows the heart and lungs 
to be normal. 

(Subsequent history.) Laparotomy was perfc^rmed by Dr. Lovett on the following 
day. On opening the abdomen a stream of pale fluid was thrown into the air with consider- 



920 PEDIATRICS. 

able force. A quart of this fluid was removed, and was examined by Dr. Whitney. It 
proved to be a jaundiced ascitic fluid, but the examination did not reveal its cause. It had 
a speciflc gravity of 1016, and contained 2^ per cent, of albumin. It also showed bile pig- 
ment. The sediment contained much blood, many red corpuscles, an occasional white cor- 
puscle, and fat-corpuscles. The flocculi were composed of finely granular material showing 
in places cells in a state of fatty degeneration. 

After the fluid was evacuated a digital examination showed extensive adhesions in the 
intestine, especially on the under surface of the liver, where nothing but a matted mass 
could be found. On the supposition that there was some obstruction to the flow of bile 
into the intestine, an attempt was made with the finger to free the intestine from the lower 
surface of the liver. 

The child rallied well from the operation, and thirty-six hours later a small spot of 
yellow bile appeared in one of the white movements. After this time bile was passed regu- 
larly and the movements became normal. The child's general condition and its nutrition 
improved. 

At the end of ten days it was taken home, but it soon began to fail, and after three 
weeks died of malnutrition. No autopsy was allowed. 

Acute Peritonitis. — Infants and children of any age may be attacked 
by acute peritonitis. It may occur in cases of tuberculosis, of the infectious 
diseases, of syphilis, and, most frequently of all, of appendicitis. The disease 
in any of the above forms is exceedingly rare between the ages of six weeks 
and two years. Where some definite cause, such as one of those just 
enumerated, cannot be found, the diagnosis is at times difficult from a want 
of prominence of some of the symptoms, such as the tympanites. 

Pathology. — The pathological manifestations in" acute peritonitis are 
reddening and loss of the normal glistening appearance of the peritoneum, 
soon followed by an exudation varying from a serous to a thick fibrino- 
purulent character. This exudation glues the coils of intestine together, 
forming adhesions, which, however, can be readily separated without the aid 
of a knife. 

Symptoms. — The symptoms of acute peritonitis vary according as the 
process is general or localized. The localized form of peritonitis corresponds 
in its symptoms to what I have already described in speaking of appendici- 
tis, which is its most frequent cause. In general peritonitis the symptoms 
in infants, as I have already stated, are often obscure. In children the 
symptoms are usually pronounced and characteristic. The child is attacked 
with abdominal pain and with general abdominal tenderness. The abdomen 
becomes distended and tympanitic, and the child assumes the position which 
will most relax the abdominal walls, — that is, with the thighs flexed and 
the knees bent. Vomiting is very apt to be present, and is augmented 
when food is given. The bowels are often constipated, although at times 
there may be diarrhoea. The temperature is usually high, 38.3° to 40.5° C. 
(101° to 105° F.) ; in some cases, however, the temperature may be normal 
or subnormal. The pulse is small and rapid. The respirations are not only 
accelerated, but also superficial, as deep respiration causes pain. The face 
has an anxious expression, and shows great suffering. Where recovery 
takes place, these symptoms gradually subside after a few days, the tender- 
ness, pain, and tympanites disappear, and the child's face assumes a tranquil 



DISEASES OF THE LIVER, PANCREAS, SPLEEN, AND PERITONEUM. 921 

look. When improvement does not take place, the pulse becomes weaker 
and quicker, the breathing more superficial and rapid, there is chilling of 
the extremities, and the child dies usually within a week. 

Prognosis. — The prognosis in these forms of acute general peritonitis 
is always serious. Constant vomiting makes it especially grave. 

Treatment. — In treating cases of acute general peritonitis when seen 
in the early stages, a saline, such as sulphate of magnesium, can be given in 
doses of 1.87 c.c. to 3.75 c.c. (J to 1 drachm), according to the age of the 
child. When, however, the disease is more advanced and there is great 
pain, opium will have to be resorted to. Where the peritonitis is of a 
high grade, where repeated doses of opium are demanded to relieve the 
pain, and where from the severity of the symptoms it is probable that a 
fluid beginning to be purulent is present, the case should at once be placed 
in the hands of a surgeon, as the question of laparotomy will then have to 
be decided. 

I find in my notes the record of a case of general peritonitis : 

An infant (Case 447), nineteen months old, previously apparently healthy, was attacked 
with vomiting and diarrhoea. On the following day the face was pale, the ala^ nasi were 
working slightly, the respirations were 36, and the temperature was 39.4° C. (103° P.). 
The respirations gradually increased to 74, and the temperature rose to 40.3° C. (104-6° F.). 
The] abdomen became very much distended and tender, and the face pinched and anxious. 
On the evening of the second day from the onset of the disease the temperature rose to 
41.1° C. (106° F.), the infant became very restless, the pupils were contracted, and death 
took place a few hours later. 

The autopsy was made by Dr. W. F. Whitney. 

The heart and lungs were normal. 

The spleen was enlarged, and was covered with a fibrinous exudation. 

The kidneys were pale, and normal in size. 

The liver was covered with flakes of recent lymph, and on section showed the acini to 
be red and their periphery yellowish and opaque. The mesenteric lymph-glands were 
slightly enlarged, and the smaller ones were translucent on section and presented evidence 
of hyperplasia. A small pocket of the larger glands was found to have become cheesy in 
the central portions, and in two of these the process had extended through the substance 
of the gland and had broken through its peritoneal covering. About these points of rupture 
there was a small zone of reactive inflammation. 

Pathological Diagnosis. — Acute general peritonitis, which, from an absence of any 
other source, must be considered to have been caused by the rupture of the cheesy, de- 
generated mesenteric glands. 

In this case the high temperature and the distended abdomen rendered the diagnosis 
comparatively clear. The case is important on account of the cause, for there is seldom any 
noticeable enlargement of the mesenteric glands under the age of three years, and these 
glands seldom soften, but either retrograde or harden from calcification. 

Chronic Peritonitis. — When acute peritonitis is localized in one por- 
tion of the intestine it may become chronic and form fibrous adhesions, but 
in the majority of cases chronic peritonitis, especially when general, is of 
tuber culai^ origin. 

Tubercular Peritonitis. — The original source of the tubercular process 
is often obscure. It may be primary in the peritoneum, but is more likely 
to be secondary to tubercular mesenteric glands. 



922 PEDIATRICS. 

Pathology. — The process consists in the formation of miliary tuber- 
cles on the peritoneal surface, which give rise to opaque cheesy thickening, 
often nodular, with firm adhesions of the adjacent surfaces. An exudation 
into the peritoneal cavity is usually present, the quantity generally being 
considerable and the quality fibrino-purulent. 

Symptoms. — The initial symptoms of tubercular peritonitis are usually 
ill defined. There is a gradual loss of appetite and flesh, with occasional 
abdominal pain, which, as a rule, is not of a severe character. Attacks of 
diarrhoea are common, and are apt to be paroxysmal. The temperature is 
at times raised, especially in the latter part of the day. After these general 
symptoms have lasted for a number of weeks, the abdomen is noticed to be 
distended. A physical examination may show that there is nothing abnor- 
mal in the thorax, and that the morbid condition is confined entirely to the 
abdomen. At first the abdomen is resonant on percussion, but later may 
be dull, owing to masses of tubercle or to the presence of fluid. There is 
seldom any tenderness noticed on examining the abdomen. 

Diagnosis. — In a typical case, where the symptoms which I have just 
mentioned are present, the diagnosis is not difficult. Occasionally, how- 
ever, there are no definite signs by which a diagnosis can be made, the 
only tangible sign being a seeming abdominal tumor, the resemblance of 
which to other abdominal tumors is so close that the diagnosis can be 
made only by laparotomy. You must nevertheless remember that most 
doubtful cases of abdominal tumors in children are tubercular. 

Prognosis. — When untreated, the prognosis of tubercular peritonitis is 
very variable. In some cases the disease after a number of months retro- 
grades, and the patient recovers. In most instances, however, the child 
becomes more and more wasted, the fever becomes more pronounced, the 
diarrhoea continues, the emaciation becomes extreme, and the child dies, 
usually of exhaustion. The surgical treatment of the disease has made the 
prognosis much more favorable. 




Tubercular peritonitis. Male, 9 years old. 

Treatment. — The treatment of tubercular peritonitis is essentially 
surgical, especially where there is ascites of any amount. In some cases, 
opening the abdomen and evacuating the fluid will not only give relief but 
will produce a permanent cure. In my experience at the Boston Children's 
Hospital, this procedure is often followed by complete arrest of the disease. 

I have some cases of tubercular peritonitis here in the wards to show 
you. 



DISEASES OF THE LIVER, PANCREAS, SPLEEN, AND PERITONEUM. 923 

This colored boy (Case 448, I., page 922) is nine years old. 

His father died of phthisis. He has never been strong, but has had no acute illnesses. 
Three weeks ago he began to have diarrhoea, and soon after enlargement of the abdomen. 
There was no pain, vomiting, nor cough. He has lost greatly in weight. You see that he 
is emaciated. He has a temperature of 38.3° C. (101° F.). His abdomen is much dis- 
tended, and there is a distinct wave of fluctuation. Physical examination shows nothing 
else abnormal. 

Case 448. 




Tubercular peritonitis. Four months after operation. 

(Subsequent history.) Laparotomy was performed by Dr. Bradford, and the fluid 
evacuated. Tubercle-bacilli were found in the peritoneal tissue. When seen six months 
later the wound had healed perfectly, and he was strong and well. This picture (II.) was 
taken four months after the operation. 




Tubercular peritonitis. Male, 'i years old. 

This next case (Case 449, 1.), a boy, two years old, is especially interesting in regard to 
diagnosis. 



924 



PEDIATRICS. 



He has not had general symptoms of serious import, but has lost slightly in weight, 
appetite, and strength. From time to time during the last six months he has complained 
of abdominal pain and tenderness. An examination of the abdomen shows a hardened, 
slightly irregular mass extending directly across the abdomen from one side to the other, 
5 cm. (2 inches) above and the same distance below the umbilicus. It is not especially 
tender on pressure. Nothing else abnormal is detected about the child. As you see (II.), 
the line of percussion does not change when he is lying on his back, and there is no evi- 
dence of ascites. 

Case 449. 
II. 




Tubercular peritonitis. 

(Subsequent history.) Laparotomy was performed by Dr. Lovett, and a mass of cheesy 
nodules matting together the intestine was found. An examination of a portion of this 
mass showed the presence of the bacillus tuberculosis. No fluid was present. The child 
recovered, but sufficient time has not elapsed since the operation to allow us to decide 
whether the disease will return. 

Case 450. 
I. 




Tubercular peritonitis. Male, 4 years old. 

This boy (Case 450), four years old, was brought to the hospital some months ago with 
the extreme distention of the abdomen which you see represented in this picture (I.). 




Tubercular peritonitis (after opteration). 



DISEASES OF THE LIVER, PANCREAS, SPLEEN, AND PERITONEUM. 925 

A physical examination showed nothing abnormal except in the abdomen, which was 
dull on percussion and showed fluctuation in every part. The child had gradually lost in 
weight, appetite, and strength. 

Laparotomy was performed by Dr. Lovett, and a large amount of ascitic fluid evac- 
uated. Tubercle-bacilli were present in the diseased peritoneum. The wound healed, but 
in the course of a few weeks the fluid reaccumulated, and laparotomy was again perfoimed 
by Dr. Lovett. You see his condition now (Case 450, II., page 924), some weeks after the 
second operation. JSTo fluid can be detected. 

(Subsequent history.) There was no recurrence of the ascites, and the child recovered 
completely. 

This boy (Case 451) is eleven years old 




Tubercular peritonitis. Male, 11 j^ears old. Four years after operation, showing scar under umbilicus. 



He is, as you see, well and strong, and shows no symptoms of tubercular disease. You 
will notice the scar under the umbilicus, which marks the line of incision made when the 
laparotomy was performed. 

Case 451. 
II. 




Tubercular peritonitis. 

He entered the hospital four years ago, and here it 
taken at that time. 



picture (II.) of him which was 



926 PEDIATRICS. 

He had been perfectly well until four months before coming to the hospital, when he 
began to lose in weight and appetite and to show an increase in the size of his abdomen. 
Although he was not especially emaciated, he had lost in flesh and was pale. The circum- 
ference of the abdomen was 76.4 cm. (30 inches). On physical examination, nothing ab- 
normal was detected in any of the other organs. 

Laparotomy was performed by Dr. Bradford, and a large amount of serous fluid of a 
dark yellow color was removed. The peritoneum was found to be thickly studded with 
minute tubercles, and tubercle-bacilli were demonstrated. The peritoneal cavity was irri- 
gated and drained. 

For some months before the boy was attacked with tubercular peritonitis he had been 
drinking the milk of a tuberculous cow. 



DIVISION XV. 

DISEASES OF THE KIDXEYS, BLADDER, AXD 
GENITAL ORGAi\S. 



IvEcttljre: xlvii. 

KIDNEYS. — Diseases of the kidneys may be congenital or acquired. 

Congenital Diseases. — The congenital abnormalities, such as con- 
genital cystic kidney, absence of one kidney, hypertrophy of the remaining 
kidney where one is absent, anomalous shapes of the kidney, and malposi- 
tions of the ureters, are important, but are so closely connected with purely 
surgical questions that they need merely be referred to in a medical lecture. 
The lobulated kidney, which I have already described (page 44, Fig. 9) as 
a normal condition in intra-uterine life, may to a greater or less degree 
continue into infancy and childhood, but has no pathological significance. 
Movable kidneys are rare in early life, but have been reported. 

Acquired Diseases. — Eenal disease as a primary aifection in infancy 
and childhood has been considered rare, but this view has been modified by 
later bacteriological investigations, which have shown that nephritis is not 
uncommon in cases of general infection. Secondary renal lesions are com- 
paratively common. 

Renal diseases, with the exception of the nephritis following scarlet fever, 
have not been satisfactorily studied in children. A series of systematic ex- 
aminations of the urine, in connection with later post-mortem examinations of 
the kidneys in the same cases, sufliciently extended to give us data for a pre- 
cise diagnosis in an especial case, has not yet been made. Owing to the varia- 
tion in the symptoms, the diagnosis of renal disease in the child must for the 
present depend tipon the systematic and routine examination of the urine. 

The diseases of the kidney in infancy and childhood are not so varied 
as in adults. They are chiefly represented by active hyper^emia (acute 
parenchymatous degeneration) and the nephritis following scarlet fever, 
which I have already fully described in my lecture on scarlet fever. 

Physiological Albuminuria. — Before speaking of the diseases of 
the kidney I shall describe a condition which is usually called physiological 
albuminuria. 

927 



928 PEDIATRICS. 

This condition is not infrequent, and may occur at any period of infancy 
and childhood, but is most common between the fifth year and puberty. 
The amount of albumin present is, as a rule, less than one-twelfth per 
cent. It is not present in every micturition, and in many cases seems to 
depend upon over-exercise or a highly nitrogenous diet. The albumin is 
rarely present in the urine which is passed in the morning immediately 
after rising, and this is an important point in differentiating physiological 
albuminuria from periodic albuminuria due to pathological causes, such as 
uric acid. The children who have this physiological albuminuria often 
seem to be in good health, but sometimes they are rather delicate. The 
diagnosis can be made only by repeated examinations of the urine passed at 
different times in the day, and by observing the effect of exercise and diet 
upon it. The presence of blood-corpuscles or abnormal elements in any 
amount from the kidney shows that there is a pathological condition. An 
occasional hyaline cast and albumin as high as one-fourth per cent, for short 
intervals may be present. The albumin often disappears for a time and 
returns again. Children between the ages of three and seven years excrete 
nearly double the quantity of urine and of urea for each kilogramme of their 
weight that adults do. The amount of urea excreted in children between 
the ages of three and seven years is 0.973 gramme for each kilogramme of 
their weight. This fact is to be borne in mind in estimating the quantity 
of urea passed in cases of nephritis, because otherwise the kidneys might 
appear to be excreting a normal amount of urea and yet the amount be 
abnormally small for the age. 

The prognosis in these cases of physiological albuminuria is good, and, 
so far as I know, no cases have been reported in which the condition ter- 
minated in nephritis. 

The treatment of this condition is to regulate the diet, exercise, and 
general hygiene carefully. If the children are anaemic, iron is indicated. 

General Pathology and Etiology. — According to Councilman, to 
whom I am indebted for much information on this subject, the acquired 
diseases of the kidney in childhood show considerable differences from the 
renal diseases of the adult. In childhood there is a greater liability to those 
acute affections, such as scarlet fever, measles, and diphtheria, in the course 
of which nephritis is apt to appear. Children under the age of fifteen 
years are less subject to many pathological conditions, such as disorders of 
the circulation, which in the adult frequently lead to chronic lesions of the 
kidney. Children do not usually have those disorders of the circulation 
w^hich result in granular kidney, for lesions of the arteries, especially the 
condition known as arterio-sclerosis, do not commonly occur in childhood. 
While it is true that typical examples of the small granular kidney are 
sometimes met with in children, these lesions of the kidney are primary, 
and the lesions of the circulatory system are secondary and dependent on 
the renal lesions. A part of the chronic diseases of the kidney in the adult 
is without doubt to be referred to the continuous action on the kidney of 



DISEASES OF THE KIDNEYS, BLADDER, AND GENITAL ORGANS. 929 

slight pathological conditionSj an action from Avhich the child's age protects 
it. One pathological lesion not perfectly recovered from, moreover, makes 
the kidney more prone to disease, and a greater effect ^vill be produced a 
second time by the same cause, and chronic disease will result. In the 
kidney of the adult, with the advance of years there is a gradual decline in 
the power of regeneration, and slight troubles are not readily recovered from. 
The kidney of the child, on the other hand, is an organ which possesses 
great power of growth and regeneration. For this reason a condition 
which in the adult organ is either not recovered from at all, or lays the 
foundation for chronic disease, will in childhood result in complete recovery. 
Again, the child is not exposed to certain conditions w^hich are productive 
of chronic lesions, or which may lay the foundation for them. Among these 
may be mentioned alcoholism and excesses of various sorts. Many cases 
of nephritis in the adult are to be referred to causes acting not through 
the blood, but through the urinary tract. The child, on the other hand, is 
not exposed to the dangers arising from hydronephrosis and pyelonephritis, 
except to a very limited degree. Although the causes of disease are less 
numerous and less common in children than in adults, yet when the same 
etiological factor is present the same morbid condition is produced in the 
kidney. The various cachectic conditions will lead to amyloid infiltration 
in the child as they do in the adult, and amyloid infiltration of the kidney 
makes up by far the larger part of the chronic cases of albuminuria in 
children. We may also meet with certain chronic lesions in the child's 
kidney, such as are seen in tuberculosis, and these may lead to albuminuria 
and nephritis. 

The acute diseases of the kidney, as a rule, either tend to recovery or are 
in themselves fatal ; so that only a small number of chronic diseases are 
met with which result from the acute diseases. Tliese are not to be referred 
to the continuous action of the poison of the acute disease, but to the effect 
on the kidney of the lesions produced by the acute process. An example 
of this is the condition of chronic nephritis after scarlet fever, where the 
acute lesions gradually pass into the chronic. These chronic lesions are to 
be attributed to the disorders in the circulation of the organ brought about 
by the destruction of the glomeruli. 

General Symptomatology. — The general symptoms connected with 
the various forms of nephritis are so similar that it will be less confusing 
to mention first the common symptoms which may occur in any of the 
forms of nephritis, and then to describe the etiology, pathology, and urinary 
examination of the different forms. 

One of the most common symptoms in nephritis is oedema, which occurs 
frequently in acute nephritis and in chronic i)aren('hymat(>us nephritis. The 
oedema generally appears first in the eyelids, and tlien iu the liniuls and feet. 
There may be general anasarca. Not infrequently, however, (vdema is absent 
or not marked. Vomiting is not infrequent in the beginning of the disease, 
and in some cases is, perhaps, due to the heightened temperature. It ma}' 

59 



930 • PEDIATRICS. 

occur later in the disease as a symptom of ursemic poisoning. In such cases 
there is marked diminution in the amount of the urine^ or even suppression. 
A peculiar dull white color of the skin is not uncommonly seen in chronic 
parenchymatous nephritis^ and is quite striking. In acute nephritis fever is 
often present to a greater or less extent, but is a variable symptom. Lack 
of appetite, and weakness, are common in both acute and chronic nephritis. 
Headache is a variable symptom. It is a common symptom of uraemia, 
and sometimes the only one. Amaurosis may occur as the result of albu- 
minuric retinitis, or it may be a functional symptom of the ursemic poison- 
ing and disappear later if the patient recovers. Hypertrophy of the left 
ventricle is apt to occur in interstitial and chronic parenchymatous nephritis. 
Both diseases are, however, very uncommon in childhood. In acute nephri- 
tis following scarlet fever dilatation and moderate hypertrophy of the left 
ventricle are not uncommon. Transudation into the serous cavities has been 
reported in a number of cases, as has also oedema of the larynx. 

Before I mention the details of the urinary analyses in the various dis- 
eases, you should understand that in all cases of nephritis the amount of 
urea should be carefully estimated from time to time, as a decrease in the 
urea always shows a pathological condition, and a return to the normal 
amount is usually indicative of recovery unless there is a complication with 
some other disease. Any interference with metabolism, whether in the 
liver or in the lung, may diminish the amount of urea in the urine. In 
children during convalescence from acute nephritis the urea returns to or 
exceeds the normal amount, while in chronic nephritis it is always diminished, 
as it is in adults. A sudden and excessive diminution of the urea in acute 
nephritis is suggestive of uraemia. In acute and chronic nephritis the 
chlorides are diminished when an effusion such as ascites is increasing, and 
gradually return to the normal amount as the effusion is absorbed. 

Active Hypersemia (Catarrhal Nephritis. Acute Parenchymatous 
Degeneration). — Etiology. — An active hypersemia of the kidney may arise 
in the course of various acute infectious diseases. It may also be caused 
by an excess of uric acid, and by such irritating drugs as turpentine, can- 
tharides, and arsenic. When the action of these causes is very intense, an 
acute nephritis may result. 

Pathology. — The pathological conditions resulting from active hyper- 
semia of the kidney are a gradual degeneration and desquamation of the 
renal epithelium, and an injection of the blood-vessels. There is also to 
some extent an infiltration of round cells. The process seems to affect 
chiefly the epithelium of the tubules. 

Symptoms. — Unless the hypersemia is very pronounced, there are, as a 
rule, no general symptoms, though oedema and other symptoms may rarely 
be present, as in acute parenchymatous nephritis. 

Diagnosis. — The diagnosis is made by the examination of the urine. 
The urine is clear, and its color is often normal. The amount is diminished. 
The specific gravity is higher than normal. There is a slight sediment, with 



DISEASES OF THE KIDNEYS, BLADDER, AND GENITAL ORGANS. 931 

a trace of albumin, perhaps one-eighth per cent., or at times a little more. 
Microscopic examination shows the presence of renal epithelium and blood- 
corpuscles ; the latter, however, not in sufficient number to color the urine. 
There are also leucocytes, and hyaline and fine granular casts, with an occa- 
sional epithelial cast and blood cast ; the last three varieties, however, are 
not very numerous. 

Prognosis. — The prognosis in active hyper^emia of the kidney is good, 
and the pathological condition usually disappears ^vhen its cause has been 
removed. 

Treatment. — The child should be placed on a diet exclusively of milk, 
so as to avoid any further irritation of the kidneys, and should be made 
to drink a great deal of water. It should be kept quiet, and its general 
hygiene should be carefully regulated. 

I have here a case (Case 452) which is probably one of active hypersemia. This boy, 
aged five years, had varicella when he was six months old, and measles when he was one 
year old. He had no other diseases until three weeks ago, when, without any apparent 
cause, he is said to have had a convulsion and to have vomited. He has never had any 
oedema, and a general physical examination shows nothing abnormal. An examination of 
the urine shows it to be high-colored and cloudy, to have a specific gravity of 1016, a large 
trace of albumin, and a yellowish-brown sediment consisting of amorphous urates. A 
microscopic examination shows the presence of uric acid crystals, hyaline, granular, and 
epithelial casts, and a few leucocytes. The total amount of urine passed in the twenty-four 
hours is from 360 to 450 c.c. (from 12 to 15 ounces). Heating the urine causes the high 
color, cloudiness, and brown sediment to disappear. 

(Subsequent history.) Three weeks later there was only a slight trace of albumin in 
the urine, which was of a normal color, had a specific gravity of 1020, and contained a few 
hyaline and granular casts. A few weeks afterwards the urine was found to be normal. 
No other abnormal symptoms occurred during the whole course of the disease. 

Passive Hypersemia. — In addition to the active hypersemia which I 
have just described, a chronie passive hypersemia may occur, dependent upon 
diminished arterial or increased venous pressure. This condition occurs in 
chronic cardiac disease with disturbance of compensation, in chronic pulmo- 
nary disease, and where there is mechanical hinderance to the venous circula- 
tion, as from the presence of abdominal tumors. 

Symptoms. — The symptoms which occur in the course of passive hyper- 
semia are not referable to the kidney, but depend upon the disease \\hicli 
causes the hypersemia. The urine in this condition is high-colored and often 
considerably diminished in amount. It has a high specific gravity, and 
often a heavy sediment of amorphous urates. There is a slight trace of 
albumin, usually under one-eighth per cent. Microscopic examination 
show^s a few hyaline casts with renal cells adherent, and an occasional blood- 
corpuscle. There are, however, very few of these elements in the sediment. 
The peculiarity of the urine in passive hyperasmia is that it varies. If the 
heart becomes stronger, the urine is passed in larger quantities, is not so 
highly colored, and contains a smaller amount of albumin. 

Prognosis. — The prognosis in cases of passive hypera^nia of the 
kidney depends upon the cause of the condition. 



932 PEDIATRICS. 

Treatment. — The treatment is to be directed to the cause or causes 
of the congestion. 

Acute Nephritis. — Etiology. — The most common cause of acute 
nephritis is scarlet fever. Other diseases in the course of which it may 
arise are diphtheria, measles, varicella, erysipelas, typhoid fever, malaria, 
pertussis, and pneumonia. With the exception of its occurrence in scarlet 
fever, diphtheria, and measles, the disease is not frequent. Cases have 
been reported where it has arisen in the course of extensive affections 
of the skin, such as eczema. It also occurs after the application of drugs 
to the skin, and from the internal administration of such irritating drugs 
as cantharides, turpentine, salicylic acid, and arsenic. Cases of primary 
nephritis have been reported where no cause could be found. Although it is 
difficult to estimate with certainty the importance of cold as a causative 
factor in the etiology of acute nephritis, and although it has been denied 
that cold can produce this condition, yet numerous cases have followed 
exposure to wet and cold. Many of these primary cases, however, were 
probably due to micro-organisms, as the disease has been not infrequently 
observed in connection with general septicaemia. 

Pathology. — I have already fully described the pathology of the acute 
nephritis which follows scarlet fever. In the nephritis arising from the 
other causes which I have just mentioned, the pathological changes differ 
chiefly in the degree in which the different portions of the kidney are 
affected. The process appears to be a mixed one, but some portions of the 
kidney are more involved than others. 

Symptoms. — The symptoms of acute nephritis are such as I have 
already described in my lecture on scarlet fever. In general, the symptoms 
arising in cases due to other causes than scarlet fever are the same, but less 
severe than those which I have described in connection with that disease. 
The amount of albumin and the quantity of the urine depend chiefly upon 
the degree to which the glomeruli are affected. The number of casts and 
epithelial cells depends chiefly upon the degree of the involvement of the 
tubules. The interstitial changes can scarcely be determined by the urine. 
It is well to bear in mind that the urine may vary from day to day in any 
affection of the kidneys. In one type of the ordinary diffuse nephritis the 
urine presents the following changes. The color varies from red to brown- 
ish-red, according to the quantity and freshness of the blood which it con- 
tains. The specific gravity is high. The amount is markedly diminished, 
and there may even be anuria. There is a heavy dark-red sediment, with 
a large amount of albumin, usually more than one-quarter and often one- 
half per cent. Microscopic examination shows a large quantity of blood, 
numerous renal cells, leucocytes, a large number of casts, epithelial, blood, 
and fibrinous, also both fine and coarse granular casts and a fine detritus. 
All these elements are stained yellow or brown by the blood pigment. As 
the process advances towards recovery there are usually found, in a few 
days, more abnormal blood-corpuscles showing themselves in the form of 



BLADDER, AND GENITAL ORGANS. 933 

pale rings. There are more granular casts and detritus, and fewer epithelial 
and blood casts. Fatty elements, such as fatty- renal cells and free fat, begin 
to appear. There are also more hyaline casts, usually with a few cells and 
blood adherent to them. Still later, there is a preponderance of hyaline 
casts, with fewer epithelial cells and blood-globules. During this time the 
amount of urine increases, until during the convalescence it finally rises 
above the normal amount. The color changes to smoky, and finally becomes 
pale. The specific gravity diminishes. The albumin diminishes to a trace, 
but this trace may persist for a long time. The elements in the sediment 
become fewer. Acute exacerbations are not uncommon. 

Prognosis. — In general the prognosis is good. The disease rarely 
becomes chronic. Death may occur in the beginning from the severity of 
the disease, or later from ursemic poisoning. Some cases end fatally from 
some intercurrent disease, such as pneumonia, or from a nephritis occurring 
in the course of a general septicaemia. The majority of the cases, however, 
recover after from four to eight weeks, although a trace of albumin and a 
few hyaline casts may persist for several months, the child in other respects 
being quite well. 

Treatment. — The treatment of acute nephritis is the same as that 
which I have already described in the nephritis following scarlet fever. 

Chronic Parenchymatous Nephritis. — Etiology. — Chronic paren- 
chymatous nephritis is not a common disease in childhood, and its etiology 
is still very obscure. Some cases have followed an attack of acute nephritis, 
and in these there has generally been an interval during which the urine 
has simply contained a trace of albumin and a few casts, the symptoms of 
a chronic affection of the kidney appearing later. Cases have also occurred 
in connection with long-continued suppurative processes in the bones, joints, 
or elsewhere, arising in the course of tuberculosis or syphilis. In these 
cases amyloid infiltration is also apt to occur. There are also instances 
where no cause whatever can be discovered. 

Pathology. — The pathological condition is the same as in the adult. 

Symptoms. — The symptoms of chronic parenchymatous nephritis are 
insidious in the beginning and are prolonged. There are marked pallor, 
a tendency to oedema, and a transudation into the serous cavities. Cardiac 
hypertrophy, weakness, loss of appetite, headache, and at times vomiting 
and diarrhoea, are among the common symptoms. Retinal changes some- 
times occur, and there is a tendency to intercurrent diseases, such as pneu- 
monia and pleurisy. Ursemic intoxication may be expected later. The 
urine may be high or pale in color. It is diminished in amount, but not 
markedly so, as in acute nephritis. The sediment is usually heavy. The 
specific gravity is diminished. There is a large amount of albumin, often 
one-half per cent, or more. There are frequently amorphous urates in the 
sediment, which must be removed by heat before the microscopic examina- 
tion is made. Microscopic examination shows a characteristic preponder- 
ance of fatty elements. There are fatty renal cells, free fat, fat in the casts, 



934 



PEDIATRICS. 



and cells completely fattj. There are also compound granular cells, and 
granular, epithelial, and hyaline casts. There are often acute complications 
in the kidney, in which case the amount of urine becomes markedly dimin- 
ished, and the sediment shows blood, blood casts, and epithelial casts in addi- 
tion to the large number of fatty elements. When the disease is complicated 
with amyloid infiltration, the diagnosis of the latter can hardly be made 
from the urine. 

Pkognosis. — The prognosis is not good. Some cases having the clinical 
symptoms of the disease have apparently recovered. Most cases, however, 
die from ursemic intoxication or from some intercurrent disease, such as 
pneumonia. There may be a remission in the symptoms for a time. 

Treatment. — The treatment is to restrict the diet as far as possible 
to milk. Good hygienic surroundings, and as much rest as possible, are 
indicated. Diuretics may be used when the amount of urine is diminished. 
I have already described in my lecture on scarlet fever the best treatment 
with diuretics (page 563). 

Here is a boy (Case 453), eleven years old, with nephritis which has lasted a year. 
The examination of the urine by Professor Wood shows the probability of a chronic 
parenchymatous nephritis with an acute exacerbation. 



Case 453. 




Probable chronic parenchymatous nephritis with an acute exacerbation. Male, 11 years old. 

after being out of bed five days. 



Relai)se 



This child had pertussis when he was three years old, scarlet fever when he was four 
years old, and measles and pneumonia when he was five years old. He is reported to have 
remained well from that time until nine months ago, when, without any known cause, such 
as exposure to cold or sickness of any kind, his face and eyes began to be oedematous. This 
was followed by oedema of the legs and ankles, and was accompanied by dyspnoea. The 
urine was noticed to be nearly of the color of blood, and to be lessened in amount. He was 
kept in bed for six weeks, and is said not to have complained of any especial discomfort. 
During this attack his appetite remained fair. Since the beginning of the attack he has 
grown somewhat weak and become pale. Six weeks ago the paleness and oedema about the 



DISEASES OF THE KIDNEYS, BLADDER, AND GENITAL ORGANS. 935 

eyes increased, and the urine became smoky again. This was followed by oedema of the 
ankles, feet, and legs, accompanied by dyspnoea. The bowels have been regular, and there 
has been no vomiting. He sleeps well. On entering the hospital his face looked pale 
and waxy. There was considerable oedema of the face, especially of the eyes. His tongue 
was slightly coated, and there was oedema of the ankles, feet, and legs. Nothing abnormal 
was found in the heart or lungs, and there was no evidence of ascites. 

He was kept in bed and given a diet of milk. Under this treatment the oedema and 
anaemia disappeared rapidly, and in two weeks he was allowed to be dressed and about the 
ward. This was five days ago. Yesterday he again had oedema of the face, and was 
immediately put to bed. As you see him to-day, the oedema under the eyes is espe- 
cially prominent. From 750 to 900 c.c. (25 to 30 ounces) of urine are passed in the twenty- 
four hours. An examination shows it to have a specific gravity of 1010, an acid reaction, 
to contain urea 4.75 grains to the ounce, to have the chlorides diminished, and to contain 
Y^o per cent, of albumin, but no sugar. The sediment shows numerous hyaline casts of 
medium diameter, some of large diameter from the straight tubules, many coarse and fine 
granular casts, numerous fibrinous casts, and many casts with renal cells adherent ; also 
epithelial casts and blood casts ; an excess of renal epithelium , most of it granular or fatty ; 
compound granular cells, a large amount of abnormal blood, free fat, and fatty casts. His 
temperature has varied from 36.6° to 37.2° C. (98° to 99° F.). 

(Subsequent history.) After remaining in the hospital for two months, with temporary 
periods of improvement, he was discharged in about the same condition as when he entered. 

Here is a girl (Case 454), nine years old, with nephritis. 




Probable chronic parenchymatous nephritis with an acute exacerbation, Female, 9 years old. Second 

week of the disease. 

This child had measles when she was two years old, scarlet fever when she was three 
years old, varicella when she was six years old, and pertussis when she was eight years old. 
She apparently recovered entirely from all these diseases, and was well until one week 
ago, when, without any apparent cause, her face and feet began to swell. She complained 
of no pain, and had no other symptoms. As you see her in bed, you will notice the marked 
and extensive oedema of the entire face, body, and limbs. You see that the cedema is pro- 
nounced under both eyes, but especially so under the right one. There is great pallor of 
the skin, and the feet and hands are much swollen. Nothing abnormal has been detected 



936 



PEDIATRICS. 



in the heart or lungs. There is no ascites. She has no headache, and does not complain 
of any discomfort. 

An examination of the urine shows the color to be pale, the reaction acid, the specific 
gravity 1012, the sediment moderate; it contains albumin l-\- per cent., and no sugar; 
the sediment contains considerable abnormal blood, some free fat, and a number of hyaline 
and fine granular casts of medium and small diameter, many of them short and with oil- 
globules adherent. There are some fatty renal epithelium, leucocytes, casts with renal 
epithelium, and hyaline casts with a few renal cells adherent. There are also several fatty 
casts. The casts are not very numerous. 

She is being treated by absolute rest in bed, bitartrate of potassium, digitalis, and a diet 
of milk, as I have recommended in my treatment of the nephritis following scarlet fever 
(page 545). 

I show this child because she illustrates the appearance of a case of marked nephritis, 
with its excessive universal oedema and peculiar pallor of the skin. The diagnosis of the 
exact lesion of the kidney in this case is, however, very uncertain, as the pathological 
processes in the kidney are not confined to any one part of the organ, and the urinary 
analysis is often for this reason unsatisfactory. 

Case 454. 
II. 




Probable chronic parenchymatous nephritis with an acute exacerbation. Female, 9 years old. (Ten days 

after treatment was begun.) 



I have provisionally called it a case of probable chronic parenchymatous nephritis with 
an acute exacerbation. The presence of blood may be due to an acute exacerbation, but 
might also mark it as an acute nephritis involving chiefly the parenchyma of the organ, as 
shown by the predominance of cells. It is significant in this case as pointing towards a 
chronic process that the urine has always been pale, showing that blood in sufficient quan- 
tity to color the urine has not been present. 

(Subsequent history.) In about a week the oedema rapidly diminished and the urine 
increased in amount. An analysis of the urine at this time showed that the color was pale, 
that it had a specific gravity of 1010, a trace of albumin, and a slight sediment, consisting 
of a small amount of blood, renal epithelium, and a few casts with blood. The total 
amount of urine passed in the twenty-four hours was 2010 c.c. (67 ounces). 



DISEASES OF THE KIDNEYS, BLADDER, AND GENITAL ORGANS. 937 

This picture taken at this time (II., page 936) shows how the general oedema has passed 
away, and how the skin has lost the extreme pallor which it presented on the child's entrance 
into the hospital. 

An examination of the urine three weeks later showed the color to be pale, the reaction 
acid, the specific gravity 1014, the albumin l-\- per cent. It contained hyaline and fine 
granular casts of small diameter, many with oil-globules and renal cells adherent ; also free 
oil-globules, fatty and granular renal epithelium, some normal and abnormal blood, leuco- 
cytes, and squamous cells. The casts were not very numerous, and there was not much 
change from what was found in the urine three weeks previously. At this time the urine 
again became scanty, and the oedema and pallor returned, but she did not complain of any 
discomfort. An examination of the urine eight weeks later showed it to be pale and cloudy, 
the reaction acid, the specific gravity 1018, and that it contained considerable sediment, and 
albumin ^^ per cent. The sediment consisted chiefly of hyaline casts of medium and 
small diameter, many of them having renal cells and fat adherent. There were also a few 
finely granular casts, considerable abnormal blood, free fat, fatty renal cells, epithelium, 
leucocytes, and occasionally blood, epithelial, and fatty casts. 

The diagnosis cannot be positively established until the case shall have been under 
observation for a much longer period. 

Chronic Interstitial Nephritis. — Chronic interstitial nephritis is so 
exceedingly rare in childhood that very little need be said concerning it. 
A few congenital cases have been reported. 

Etiology. — The etiology is obscure. In some cases it seems to have 
followed a chronic parenchymatous nephritis. In others no cause could be 
found. 

Pathology. — The pathology is the same as in adults. 

Symptoms and Diagnosis. — The diagnosis can scarcely be made from 
the symptoms. The disease is progressive and slow, with no characteristic 
symptoms. Cases have been reported in which there were general symptoms 
of headache, weakness, dyspnoea, palpitation, and disturbance of vision. 
Hypertrophy of the left ventricle occurs as a constant lesion. There is 
little tendency to anasarca ; retinitis may be present. Baginsky refers to 
the lack of development of the children in these cases, and this condition 
was noticed in a case of this disease which occurred at the Boston Chil- 
dren's Hospital. 

This child (Case 455), a girl, twelve years old, showed the development of a child 
of about seven years. The only symptom until she died of uraemic poisoning was per- 
sistent headache. The post-mortem examination showed marked interstitial nephritis, but 
it was not possible to determine whether it was primary or not, and no previous history 
could be obtained. 

In chronic interstitial nephritis the amount of urine passed in the 
twenty-four hours is increased. It has a low specific gravity, a very slight 
sediment, and a trace of albumin. The microscopic examination shows a 
few hyaline and finely granular casts and occasional renal cells. Some- 
times towards the end of the disease highly refractive homogeneous casts 
resembling w^ax appear in the urine. At this time the amount of urine 
may be somewhat diminished, but the specific gravity does not rise, as the 
excretion of urea is interfered with. 

Prognosis. — The prognosis is very unfavorable. The children usually 



938 PEDIATRICS. 

die of cerebral hemorrhage or of some intercurrent disease, the fatal result 
occurring in from three to four years. 

Treatment. — The treatment is symptomatic. 

Amyloid Infiltration. — In connection with amyloid changes in other 
organs, especially the liver, spleen, and intestine, amyloid infiltration may 
occur in the kidney. 

Etiology and Pathology. — It occurs at times in connection with 
chronic suppurative processes in the bones or elsewhere, and also in tubercu- 
losis, syphilis, and chronic wasting diseases. It is not, however, especially 
common in early life. 

Symptoms. — The symptoms are not referable to the kidney. The 
presence of amyloid changes in the liver and spleen, shown clinically by 
enlargement and by the examination of the urine, are the signs by which the 
diagnosis is made. The urine is usually passed in large quantity when the 
amyloid changes are advanced. The specific gravity is low, and albumin is 
present. When the amount of urine is not much increased, as may happen 
temporarily, the albumin occurs in large amount. Microscopic examina- 
tion shows no characteristic sediment ; but when, as may often happen, the 
disease is combined with chronic nephritis, the sediment will show evidence 
of this latter disease. 

Prognosis. — On account of the usual causes of this condition, the 
prognosis is unfavorable. 

Treatment. — The treatment is symptomatic. 

Pyelitis and Pyelo-Nephritis. — Etiology. — Pyelitis and pyelo- 
nephritis may be due to an extension upward along the genito-urinary tract 
of an infection caused by catheters, gonorrhoea, or cystitis. Cases due to 
these causes, however, are uncommon in comparison with those which result 
from the excretion of uric acid by the kidney or from pelvic calculi. The 
disease may also be caused by tuberculosis of the kidney and by malignant 
growths. 

Pathology. — The pathology of this disease varies with the cause. 
After the pyelitis has lasted for a time the kidney is affected in almost 
every case, and pyelo-nephritis results. 

Symptoms. — In an acute attack of the disease, as when it is caused by 
uric acid or a calculus, there are often pain and fever. Typical attacks of 
renal colic, with vomiting, pain, and fever, may occur. If the condition be 
due to tubercles, malignant growths, or abscess of the kidney, there will 
be more or less cachexia and emaciation, and there may be local pain and 
tenderness. 

The diagnosis is to be made from the examination of the urine. The 
urine contains pus, which gives it a cloudy appearance, and the sediment is 
heavy. The color varies : it may be red if there is considerable hemorrhage. 
The urine contains albumin, which varies from a trace to a considerable 
amount, according to the amount of blood or pus and the presence or absence 
of a concurrent affection of the kidney. The microscopic examination shows 



DISEASES OF THE KIDNEYS, BLADDER, AND GENITAL OEGANS. 939 

sometimes the whole field to be filled with pus-corpuscles, at other times the 
pus to be in clumps ; there are also present small round cells with single 
nuclei, from the pelvis or from the kidney, and more or less blood. The 
diagnostic cell of pyelitis is the '' caudate cell,'' which is a small cell about 
the size of a renal cell, having a single nucleus and a tail. If the kidney 
is affected there are casts of various kinds, hyaline, granular, epithelial, 
and blood. The casts may not be easily seen if the field is filled with pus. 
The presence of tubercle-bacilli in the sediment, shown by appropriate 
methods of staining, establishes the diagnosis of tuberculosis. In the 
freshly passed urine, uric acid is often present in the sediment in the form 
of irregular spiculated crystals. These may suggest the probable cause of 
the pyelitis. 

Prognosis. — The prognosis depends upon the cause. In malignant 
growths it is fatal. This is true to a greater or less degree where tubercle 
is the cause of the disease, as in almost every case it is present somewhere 
else in the body. When uric acid or a calculus is the cause, the prognosis 
is more favorable, and, as a rule, the outcome depends upon the fact whether 
the treatment is appropriate or not. 

Treatment. — The uric acid should be treated by neutralizing the acid- 
ity of the urine, by placing the child upon a mild and unirritating diet, 
such as milk, and by making it drink freely of distilled water. Operative 
treatment is at times called for where a calculus is present. 

Malignant Growths and Enlargement. — Tumors of the kidney are 
more common and more serious in the child than in the adult. The simple 
adenomata are probably equally common in both, but the child is much 
more liable to carcinomata and sarcomata than is the adult. Sarcomata are 
the most common in the first five years of life, and usually occur in one 
kidney. 

Symptoms and Diagnosis. — The diagnosis depends upon the recogni- 
tion of a tumor of the kidney and the progressive emaciation and cachexia 
which arise. At times there is pain, but, as a rule, pain is absent. The 
urine sometimes gives evidence of a pyelo-nephritis ; at other times ha?ma- 
turia and albuminuria occur at intervals, but generally late in the disease, 
at a time w^hen the tumor can be felt through the abdominal wall. Some 
of the characteristics of a tumor of the kidney are that it is located in the 
hypogastric and lumbar regions, that it is deep-seated, and that it is not so 
commonly to be felt in the umbilical region as are tumors of the retro-peri- 
toneal glands. The tumor is irregularly rounded, and usually does not have 
a well-marked border, such as is found in enlargement of the spleen and 
liver. In these cases of sarcomata of the klduey the health at first is often 
not much affected, but there are progressiv^e emaciation and enlargement of 
the abdomen, commonly without pain. 

Prognosis. — The prognosis is very unfavorable, although temporary 
relief is often obtained by means of surgical interference. 

Treatment. — The treatment is essentially operative. 



940 PEDIATRICS. 

Affections of the Supra-Eenal Capsules. — The affection of the 
supra-renal capsules called Addison^s disease has been met with in young 
children, but is exceedingly rare. 

HEMATURIA AND HEMOGLOBINURIA. — Hsematuria and hsemoglobi- 
nuria are, as a rule, easily recognized by the color of the urine if sufficient 
blood is present to color it. The color is red if it is due to fresh blood, or 
brownish red if due to blood-pigment which has been washed out of the 
corpuscles. 

To determine the source and cause of the hemorrhage is often quite 
difficult. Hemorrhage from the bladder may be caused by a calculus, or by 
papillomatous growths, or may occur in cases of haemophilia. When the 
blood comes from the bladder it is generally not uniformly diffused through 
the urine, and small clots are common. In addition to this there are symp- 
toms of disturbance of the bladder, such as tenesmus and frequent and per- 
haps interrupted micturition. In hemorrhage from the kidney the blood is 
diffused through the urine. The color may be red or brownish red. The 
microscopic examinations show epithelium and casts from the kidney, and 
the elements are stained yellow and brown from longer contact with the 
blood. There are also normal blood-corpuscles, and others from which the 
haemoglobin has been washed out, appearing as pale rings. 

Hsematuria may occur in haemophilia and in purpura. Hsematuria may 
also be a symptom of malignant growth in the kidney. It may be an early 
symptom occurring at intervals, but usually it appears at a later period, 
when the presence of a tumor can be detected by palpation. It may also be 
caused by uric acid. 

In cases of hsemoglobinuria, notsvithstanding the red or at times almost 
black color of the urine and the presence of albumin, there are no corpus- 
cles to be found. Heller's test, which consists in adding hydrate of potas- 
sium to the urine and heating it, causes a precipitation of the phosphates, 
which carry down the blood-pigment mechanically as dark-red flocculi. 
A similar appearance may be given to the urine after the administration 
of senna and rhubarb. In such cases Heller's test would give the same 
results as if blood-pigment were present. The nitric acid test for albumin 
would, however, decolorize the urine, and the test for albumin would be 
negative. It is important to recognize the very dark urine resulting from 
carbolic acid poisoning, as it occasionally occurs after the external applica- 
tion of this drug. Under these circumstances the urine has a greenish tinge. 

Etiology. — The etiology of paroxysmal haemoglobinuria is as yet ob- 
scure. The child often appears to be in good health. The most frequent 
apparent cause is cold. Certain individuals have haemoglobinuria when- 
ever they are chilled, or wet their feet, or plunge into cold water. Some 
cases of haemoglobinuria appear to be due to infection, as in scarlet fever, 
Winckel's disease, and malaria. Certain inorganic substances when taken 
by the mouth, especially chlorate of potassium, phosphorus, and arsenic, have 
produced haemoglobinuria. 



DISEASES OF THE KIDNEYS, BLADDER, AND GENITAL ORGANS. 941 

Some cases of haemoglobinuria have severe symptoms at the time of the 
attack, such as chills, cold extremities, and a rapid, small pulse. Neither 
these symptoms nor the hsemoglobinuria last very long, as a rule. At times 
it is impossible to determine the cause of the hsemoglobinuria. A case which 
has lately come under my notice shows how difficult it is to determine the 
cause of this disease even when a post-mortem examination can be obtained. 

A girl (Case 456), four years and eight months old, had for several weeks grown pale, 
lost in weight, and shown symptoms of indigestion. Later the urine was reduced in 
amount and was dark-colored. There was also slight oedema of the eyelids and feet. Xo 
other especial symptoms arose, and the child went out of the house as usual and seemed 
otherwise well. For three or four days before her death the pallor and oedema increased 
markedly, and the urine was lessened in amount and became still darker in color. About 
twenty-four hours later she became very dull, and on the following day was much blanched 
and almost unconscious, except that when she was aroused to be examined she would resist 
and scream. The urine showed the condition of haemoglobinuria. The child died a few 
hours later. 

The post-mortem examination, made by Professor Councilman, showed evidences of 
profound anaemia. The bone-marrow was red. There were haemoglobinuria, fatty degener- 
ation of the heart, liver, and kidneys, and haemoglobin casts in the tubules of the kidney. 

Chyluria. — Chyluria is a rare disease. Two forms are usually spoken 
of, the tropical and the non-tropical. 

Etiology. — The tropical form is caused by a parasite, the filaria san- 
guinis hominis, a species of round-worm. This parasite is foimd in the blood, 
and at times in the urine, especially that passed towards night. The exact 
connection between the parasite and the chyluria has not yet been determined. 
In the non-tropical form the parasite has not been found. Cases have been 
reported where the parasite appeared in an individual residing in the tropics, 
and disappeared on his returning to a cold climate, although the chyliu-ia 
continued. The chyle is supposed to get into the urine after it has left the 
kidney. 

Symptoms. — The symptoms of this disease are shown chiefly in the 
urine. The urine has a milky appearance, sometimes a sour odor, and tends 
to decompose rapidly. The reaction is slightly acid, or neutral. Micro- 
scopic examination shows the fluid to be filled with fine fat drops in suspen- 
sion. The urine at times contains blood-corpuscles, and albumin is always 
present. The attacks are apt to be paroxysmal, lasting for days or weeks, 
then ceasing and again recurring. A fatty diet may or may not cause an 
increase in the chyluria. The individuals atfected by the disease may have 
a healthy appearance. Coagula may at times be formed in the bladder and 
give rise to pain and difficult micturition. 

Prognosis. — The prognosis of chyluria is doubtful. It is a disease 
which lasts for a long time and may cause anaemia and emaciation from 
the loss of fat and albumin. 

Treat:ment. — There is no treatment which is known to be beneficial. 

Hydronephrosis. — Etiology. — Hydronephrosis may be congenital, in 
which case it may be due to constriction of the ureter. Both kidnevs mav 



942 PEDIATRICS. 

be aiFected, but usually only one is involved. When acquired it generally 
affects but one kidney, and may be caused by obstruction to the escape of 
urine either from above, as by an impacted calculus in the hilus of the 
kidney or in the urethra, or from below, by the pressure from a tumor or 
enlarged mesenteric glands. The effects are mechanical, and are due to the 
pressure of the retained fluid on the kidney, which leads to the gradual 
absorption of the kidney-substance. These tumors sometimes acquire a 
large size. 

Symptoms. — The main symptom of hydronephrosis is the presence of 
an abdominal tumor connected with the kidney. When the tumor has 
grown sufficiently large, fluctuation can be usually detected, and aspiration 
gives a fluid which ordinarily contains urea. Subjective symptoms may be 
absent. If only one kidney is affected, the other performs the function of 
both, and the general condition of the child may remain good. 

Prognosis. — The prognosis is doubtful. Cases have been operated 
upon with success both by aspiration and by removal of the tumor. 

Treatment. — The treatment of this disease is essentially surgical. 

Acute Cystitis. — Acute cystitis is not a common affection in infancy 
and childhood. 

Etiology. — It may be caused by a vesical calculus, by irritants, such as 
turpentine, and also occasionally by the extension of infection through the 
genital tract. 

Symptoms. — The symptoms of acute cystitis in children do not differ 
from those which are met with in the adult. The chief symptom is fre- 
quent and painful micturition. This local symptom is usually accom- 
panied by fever, which may be high, and by general symptoms of malaise, 
fretfulness, and crying from vesical pain. The urine is passed in small 
quantities, and, as a rule, is of a reddish color. The specific gravity is 
high. When freshly passed it is acid, but it quickly becomes alkaline ; 
there is a heavy sediment, and it contains a trace of albumin. Microscopic 
examination shows chiefly pus in large quantities, squamous epithelium, and 
some blood. To establish the diagnosis it is necessary to obtain the urine 
by the catheter, or, in females, first to wash out the vagina thoroughly, as 
the epithelium of the vagina and that of the bladder are very similar. 

Prognosis. — The prognosis of acute cystitis is good after the removal 
of the cause. 

Treatment. — The especial cause of the attack must be looked for, and 
removed if possible. The child should be kept perfectly quiet in bed, and 
should be made to drink a great deal of water. The diet should be of milk. 
Sedatives should be used freely. 

Chronic Cystitis. — Chronic cystitis may be caused in children, as in 
adults, by a vesical calculus, by foreign bodies in the bladder, by tumors, by 
papillomata, and by tuberculosis. The nuclei of the calculi are generally com- 
posed of uric acid, upon which phosphates are precipitated in alkaline urine, 
and this deposition is favored by the accompanying catarrhal inflammation. 



DISEASES OF THE KIDNEYS, BLADDER, AND GENITAL ORGANS. 943 

Symptoms. — Micturition is frequent and at times painful. Later there 
may be a constant dribbling of urine, giving rise to an offensive ammoniacal 
odor and causing irritation about the genitals. AYhere there is a calculus 
in the bladder the stream is often suddenly interrupted during micturition 
and the pain is more severe. Prolapse of the rectum is not uncommon with 
stone. In addition to these local symptoms there are general symptoms of 
anaemia and loss of weight. The urine is ammoniacally alkaline, offensive 
in odor, and turbid, has a heavy ropy sediment, and contains a trace of 
albumin. The sediment should be examined as soon as possible after the 
urine is passed, because the ammonia which is produced from the urea dis- 
integrates the cells. The examination will show a large quantity of pus, 
some blood, bladder-epithelium, and crystals of triple phosphate and urate 
of ammonium. 

Prognosis. — The prognosis of chronic cystitis depends upon the cause, 
upon the length of time during which the disease has persisted, and the 
presence or absence of a secondary affection of the kidney. 

Treatment. — The urine should be diluted by giving distilled water in 
large amount. It may be rendered less irritating by such drugs as salol 
and buchu, and less alkaline by benzoate of sodium. Washing out the 
bladder is of use in many cases, and local applications may be made in 
tuberculosis of the organ. Operative treatment is indicated when a calculus 
is causing the disturbance. 

At times it is exceedingly difficult to determine by the general symptoms 
whether a calculus is present in the bladder. I shall report to you a case 
which illustrates this difficulty. 

A boy (Case 457), seven years old, began to have pain of a spasmodic cbaracter in the 
region of the bladder during micturition. In connection with the pain there would be a 
sudden stoppage of the flow of the urine and a bearing-down feeling in the rectum. These 
symptoms simulated those of a vesical calculus so closely as to render a difierential diagnosis 
very difficult. The boy was of a nervous temperament, and was rather anaemic, but other- 
wise was well and strong. Nothing abnormal was detected about the prepuce or the rectum. 
The pain was so annoying and caused so much trouble that it was deemed advisable to 
have the bladder examined for stone. An examination was made by Dr. Bradford, and 
nothing abnormal was detected. After the bladder had been examined, a decided improve- 
ment took place, apparently connected with the passing of the sound, and the boy recovered 
entirely after remaining at home from school for a few weeks and having daily exercise in 
the open air. 

VrLYO- Vaginitis. — Yulvo-vaginitis is a very common affection in 
little girls. It arises from a Yariety of irritations, one of which is the 
oxyuris vermicularis. In a very large number of cases the gonococcus of 
Neisser has been found in the purulent secretion. The gonococcus was found 
in all of six cases lately treated at the Boston Children's Hospital. The 
disease may also arise in children who are very much debilitated, and is met 
with at times in scarlet fever and in measles. Again, it is not infrequent 
in anaemic girls, in whom it occurs without any apparent cause. 

Pathology. — The labia are reddened and are more or less swollen. 



944 PEDIATRICS. 

There is a thick, purulent discharge of a greenish-yellow color, usually 
offensive. At times there is more or less excoriation of the inner surfaces 
of the labia. The inguinal glands may be slightly enlarged and tender. 
The urethra is, as a rule, involved in the irritation, and is swollen and red. 

Symptoms. — There may be some fever in the early stages of vulvo- 
vaginitis. Smarting and burning are usually complained of, but at times 
the staining of the clothing first calls attention to the disease. The chil- 
dren commonly become pale if the disease persists for some time. Mictu- 
rition is painful in some cases, and the disease is one of the many causes 
of dysuria. In many cases the children appear to be quite well, with the 
exception of the local condition. 

Prognosis. — The prognosis is good, but the disease is apt to be pro- 
longed for several weeks or months. Complications may arise from the 
extension of the process into the urethra and the bladder, and cause addi- 
tional symptoms referable to these parts. 

Treatment. — Local applications to the vagina constitute the only 
satisfactory form of treatment. This is difficult in young children, but may 
be accomplished with a soft rubber catheter. Such solutions as boracic acid 
4-100, corrosive sublimate 1-5000, or creolin 1-500, may be used. In some 
severe cases local applications of nitrate of silver 1 or 2 per cent, may be 
necessary. The labia should be kept separated by absorbent cotton, and the 
parts kept dry and covered with some mild dusting-powder. Absolute 

Ftg. 1.^2. 




Gonococci contained in pus-cells from male, 8 years old. Acute stage of inflammation. 

cleanliness must be observed, to prevent infection of the eyes and of other 
persons. The parts should be protected with compresses held in place by a 
bandage, which should be Avorn all the time, and the compresses should be 
frequently changed and burned. The towels used for the patient should not 
be left lying about, and should be carefully disinfected. Tonic treatment is 



DISEASES OF THE KIDXEYS, BLADDEE, AXD GENITAL ORGANS. 945 

sometimes indicated. The urine should be kept dikite, in order to avoid 
irritating the inflamed surfaces, and any complicating cystitis should be 
treated. During the active stage of the disease the child should be kept as 
quiet as possible, and on a diet of milk. 

Where the vulvo-vaginitis is caused by the oxyuris vermicularis, especial 
care should be given to eradicating the parasite from the rectum. After 
this has been done, the vagina is readily freed from the parasite by using 
an injection of warm sweet oil, which is to be allowed to remain for three or 
fom' minutes, the vagina theu being syringed out with warm water. 

Gonorrhoea also may occur in boys. 

This boY (Case 458), eight years old, came to the hospital yesterday complaining of 
pain on micturition and on walking. The prepuce was found to be very much swollen, 
and there was a discharge of pus from the urethra. An examination of the discharge by 
Dr. Mallory showed the presence of gonococci in the pus-cells. This specimen (Fig. 130, 
page 944), taken from this case, shows the morphology of the parasite as seen by means 
of a Leitz homogeneous'oil immersion ^2) Leitz stand Oc. No. 3, tube closed. 

The gonococci are ovoidal or biscuit-shaped, and usually occur in pairs, the flat sides 
being opposed to each other. It is characteristic of them that they are found within the 
pus-cells as well as on their surfaces and free in the fluid. 

Orchitis. — Orchitis, or inflammation of the testis proper, may occur in 
childhood from direct injury, but it is a rare disease. When present it is 
commonly accompanied by hydrocele. The orchitis which so commonly 
follows mumps in the adult is less common in children. 

Epididymitis. — Besides being due to trauma, acute epididymitis may 
be caused by any irritation of the mucous membrane of the urethra. In 
this disease the whole scrotum is apt to be hot and tender, and the child is in 
great pain. The epididymis is much enlarged and exquisitely tender, and 
pushes the testis forward. The cord is often implicated, becoming enlarged 
and painful on pressure. 

The treatment should be energetic, as, owing to the swelling of the 
tissues about the testicle, there may be so much pressure that the gland will 
be seriously damaged, although the subsequent atrophy may not declare itself 
for a considerable time. The child should be kept upon his back in bed, 
the bowels freed with a cathartic, and a series of hot poultices kept upon 
the scrotum. In all inflammations of the testis or epididymis the scrotum 
should be placed in such a position that the lower end of the testicle points 
upward. 

TuBERCT'LAR DiSEASE OF THE Testicle. — As Compared with the fre- 
quency of its occurrence in adults, tubercular disease of the testicle is rare in 
infancy and childhood. When the disease is present the gland is cousider- 
ably swollen and often nodular, but rarely very tender. As the disease 
progresses, adhesions may form with the tissues of the scrotum, and the de- 
crenerated material mav be discharo-ed tlirouo-h a fistulous tract. 

General treatment is indicated if the disease is just starting, but if it 
has already destroyed the usefulness of the gland it is safer to operate 

60 



946 PEDIATRICS. 

immediately and remove the focus of infection ; here, of course, we should 
be guided by the conditions elsewhere. 

Tumors. — In addition to tubercular disease of the testis, tumors may be 
found in infancy and early childhood. These may be congenital or acquired. 
The congenital tumors are very rare, and are usually of the dermoid variety. 
The most common of the acquired tumors are sarcomata, which are very 
malignant. The rapid growth and the large size of this variety usually 
render the diagnosis easy. 

Phimosis. — In early life there appears to be a physiological adhesion 
of the prepuce to the glans penis. As the child grows older these adhe- 
sions normally disappear. When the adhesion between the prepuce and 
the glans remains permanent and the prepuce is very tight, the condition 
gives rise to various symptoms. Thus the escape of the urine may be 
mechanically hindered, and the urine collecting behind the glans may give 
rise to irritation. Smegma is also apt to collect around the corona. In this 
way an inflammatory condition of the prepuce (posthitis) or of the glans 
(balanitis) may arise. As a result of this there is swelling, and micturition 
is painful and difficult. In addition to these local symptoms many second- 
ary disturbances arise from the local reflex irritation. Among these are 
nervous phenomena of greater or less degree, such as convulsions. Phimo- 
sis may lead to enuresis and masturbation. 

In all cases of phimosis local treatment is indicated, and may be by 
dilatation, incision, or circumcision. — the latter being the most radical and 
producing the best results for complete relief from the morbid condition. 
In all cases, even if the phimosis is very slight, mechanical interference 
should be persisted in until absolute cleanliness can be secured, for in this 
way only will entire relief from the local and reflex symptoms be obtained. 

Anuria. — I have already spoken of the forms of anuria which result 
from suppression of the urine in nephritis. Anuria may also occur in 
infants and in young children irrespective of any disease. The infant 
will not pass its water for perhaps twenty-four hours, apparently from na 
especial cause. 

Hot applications over the bladder and making the child drink an 
increased amount of water will usually relieve this condition. It seldom: 
calls for the use of the catheter, and serious results need not be apprehended. 

Enuresis (Incontinence of Urine). — Enuresis is a condition in which 
there is an involuntary discharge of the urine. It may be continuous or 
periodic. It may also be diurnal, nocturnal, or both. It is of very frequent 
occurrence in infancy and early childhood. It is a symptom rather than a 
disease, and in most cases is a true neurosis. During the first year of life the 
infant has not learned to assume control of the mechanism of micturition, 
but during the second year this control is usually attained at an earlier or 
a later period according to the individual. 

Etiology. — The causes of enuresis may be organic or functional, the 
latter in all probability being very commonly of a reflex nature. 



DISEASES OF THE KID^'EYS, BLADDER, AND GENITAL OEGANS. 947 

The organic causes comprise such malformations as small ureters, a 
small bladder, exstrophy of the bladder, and hypospadias. Enuresis may 
also be caused by central lesions of the brain and cord. 

The prognosis and treatment of these organic cases of enuresis vary 
according to the conditions which cause them, and need not be considered 
here. In a large number of cases the children are of a highly nervous 
temperament, but enuresis is also often present in children who otherwise do 
not show any nervous symptoms. As has been stated by Rachford in an 
admirable paper on this subject, this condition may depend upon (1) irri- 
table and unstable nerve-centres, (2) anaemia with malnutrition, and (3) 
reflex stimulation of certain nerve-centres in the lumbar cord. The lon- 
gitudinal and circular muscular fibres of the bladder, which by their con- 
traction empty the bladder, are innervated by sensory and motor nerves 
from the lumbar region of the cord, and the external sphincter in the pros- 
tatic portion of the urethra, which by its contraction prevents the escape of 
urine from the bladder, is also innervated by sensory and motor nerves from 
the lumbar cord. The researches of Von Zeissl show the manner in which 
reflex causes may act in starting or checking the flow of the urine. Thus, a 
reflex carried to the proper centre in the lumbar cord would, through the 
motor fibres of the erector nerve, contract the muscular coat of the bladder, 
and through the inhibitory fibres of the same nerve relax the sphincter 
vesicae. In this manner the urine which is being expelled by the contract- 
ing bladder is allowed to pass without hinderance through the relaxed 
sphincter vesicae. It is also to be remembered that the act of urination is 
in part under the control of the will. Admitting these anatomical and 
psychical facts, it is easily understood how the causes which produce enuresis 
may act in two ways : either directly on the centres in the lumbar cord, 
making them more irritable or unstable, and in that way increasing their 
reflex excitability, or indirectly through exaggerated reflex causes that affect 
both accelerator and inhibitor influences sent to the bladder. These influ- 
ences may be psychic, originating in the brain, or may be the result of 
external irritation originating in or near the bladder itself. 

There is also during childhood a lack of development of the centres of 
inhibitory reflex acts, and in this way the muscular fibres of the bladder, 
having no inhibitory restraint, are excited to action by even so slight a 
reflex cause as a small quantity of urine in the bladder. For this reason 
enuresis is a normal condition during infancy, and ceases when the child's 
inhibitory mechanism is more developed (Soltmann). The inhibitory influ- 
ence of the will is in abeyance during deep slumber, and nocturnal inconti- 
nence is therefore more frequent than diurnal. In any diseases which are 
accompanied by amemia and malnutrition the reflex irritability of the 
lumbar nerve-centres is much increased, and enuresis may result. Reflex 
enuresis may be caused by irritation in any portion of the geuito-urinary 
tract, as by a vesical calculus, cystitis, vulvitis, phimosis, very acid urine, 
and over-filling of the bladder, as in diabetes, or by an irritation of some 



948 PEDIATRICS. 

neighboring part, such as may arise from a polypus or the oxyuris vermicu- 
laris in the rectum. 

Symptoms. — As a symptom, enuresis is simply the inyoluntary empty- 
ing of the bladder. 

Prognosis. — The prognosis of enuresis varies greatly, according to the 
cause and the individual. In a large number of cases the enuresis lasts for 
only a short time, but in some cases it may continue throughout childhood : 
almost invariably, however, it ceases between the twelfth and the fourteenth 
year. The cases in which enuresis does not disappear at puberty are nearly 
always in girls. 

Treatment. — The treatment of this functional form of enuresis is 
often very unsatisfactory. According to my experience, in quite a number 
of cases the disease is intractable and is not affected by any treatment 
whatever, the individual finally recovering without treatment. After a 
careful examination has shown that no malformation or central nervous 
lesion is present, the urine should be examined, to determine if it is abnor- 
mally acid. When this is found to be the cause of the irritation, a rapid 
cure can be effected in some cases by simply diluting the urine. In females, 
especially when there is irritation around the meatus urinarius, local appli- 
cations are of great service, and in some cases dilating the urethra will pro- 
duce a permanent cure. Where phimosis is present, relief has been some- 
times obtained by circumcision. The bowels should be regulated, and it is 
well to have the child pass its water just before going to sleep, and to rouse 
it in the middle of the night in order that it may empty its bladder. The 
foot of the bed should be raised, in order that the urine shall not irritate the 
neck of the bladder. There is no especial drug which in my experience can 
be relied upon in curing enuresis. Where the children are anaemic and de- 
bilitated, iron and nux vomica are indicated. Where there is excessive irri- 
tability of the nerve-centres, belladonna and atropine are at times efficient 
in relieving this condition ; but in many cases they fail to produce beneficial 
results even when given in toxic doses. Faradism applied to the perineum, 
or to the base of the sacrum and to the symphysis pubis, is in some cases 
beneficial. There is, however, no routine treatment for enuresis. Each 
case should be studied closely, and in many instances when the especial cause 
of the condition has been found the enuresis can be relieved. 



DIVISION XVI. 

DISEASES OF THE LARYNX, TRACHEA, LUNGS, AND 

PLEURA. 



IvKctxjre: xIvViii. 

DISEASES OF THE LARYNX AND TRACHEA. 

Larynqospasmus. — New Growths. — Foreign Bodies. — (Edema. — Laryngitis. 

LARYNX. — The affections of the larynx which occur most commonly 
in infants and young children are neuroses, new growths, lesions produced 
by foreign bodies, oedema, and laryngitis. 

Laeyngospasmus (Laryngismus Stridulus). — The neurosis which es- 
pecially affects the larynx in infancy and childhood is what I have already 
described under the name of laryngospasmus when speaking of reflex irri- 
tation of the larynx in my lecture on Nervous Diseases (page 747). I shall 
therefore merely refer you to what I said at that time concerning it. 

New Growths. — New growths in the larynx in infants and children 
are rare. They may be congenital, but these are very uncommon. They 
may be malignant, such as epitheliomata and sarcomata, or benign, such as 
fibromata, myxomata, and papillomata. Those of the former class are so 
rare that they need here only be referred to. Of the latter class the fibro- 
mata and myxomata are too rare to be more than mentioned. The papillo- 
mata, on the other hand, although rare, are the most common laryngeal 
growths in early life. They may produce such serious results that it is 
important to recognize them at once. They may be congenital. Theii' 
cause is not known. Papilloma of the larynx in young children is usually 
multiple. 

The symptoms of this growth appear at about the first, second, or third 
year. The first symptom that is noticed is hoarseness. This hoarseness, 
instead of passing off in a few days, as is common where it arises from other 
affections of the larynx, continues and grows more marked. The next 
symptom is dyspnoea. This appears at intervals of a few months, or may 
not arise for some years after the first alteration of the voice. The dyspnoea 
first appears at night, when the child is asleep. In the daytime, when the 

949 



950 PEDIATRICS. 

child is awake and running about, it may breathe freely. As the papillo- 
mata increase in size, the dyspnoea appears in the daytime also, especially 
when the child makes any exertion. When the child is awake and is quiet 
the breathing may not be noticeably affected, even after the growth has 
attained a large size. Cough may be present. Usually there is no pain 
or difficulty in swallowing. When a child presents these symptoms a 
careful laryngoscopic examination should be made at once, as in this way 
only can the diagnosis be verified. 

The prognosis in these cases is bad unless the growths are removed. 

The best treatment of multiple papillomata is to etherize the child and 
remove the growths through the mouth. 

The difficulty of removal is in some cases so great that some of the most 
competent operators have preferred to postpone the operation until the child 
is older, or until the symptoms are so urgent that there is danger of suffo- 
cation. The child during this time must be kept under strict supervision, 
but local applications are not indicated. These growths, even when com- 
pletely removed, have a tendency to recur. 

Foreign Bodies. — Foreign bodies rarely lodge in the larynx, but this 
accident occurs more commonly in children than in adults, as children are 
apt to put articles of every description into their mouths. 

The symptoms which indicate the presence of a foreign body in the 
larynx are an attack of sudden suffocation and a change in the sound of the 
voice in a child who has previously shown no signs of obstruction and no 
symptoms of laryngeal disease. 

The accident is one which is so serious that the child should be placed 
at once in the hands of a laryngologist. The larynx should be examined 
with the laryngoscope, and the foreign body removed, if possible, with the 
forceps. Great care should be taken not to push the foreign body into the 
trachea, as tracheotomy would then be necessary. For the same reason it is 
inadvisable to introduce the finger blindly into the larynx, or to do any- 
thing which may cause a sudden inspiration. 

(Edema. — (Edema of the larynx is not a common condition in early 
life. It may arise from a number of causes, and is secondary to some dis- 
ease elsewhere or to some local irritation. It occurs as a rare complication 
in nephritis and in the acute exanthemata. It may arise from irritation 
produced by local lesions, such as ulcerations, from foreign bodies, from 
inhalations of hot vapors, from the swallowing of corrosive liquids, and 
also as the result of any acute inflammation, such as erysipelas. 

The diagnosis, as a rule, must be verified by a laryngoscopic exami- 
nation. 

The treatment is that of the disease or local irritation which is causing 
the oedema. The local application of cold, and, if necessary, scarification 
of the oedematous tissue, are indicated. If the attack is pronounced and 
suffocation is imminent, you should be in readiness to perform tracheotomy 
or intubation. 



DISEASES OF THE LARYNX AXD TRACHEA. 951 

Laryngitis. — The most common inflammatory lesions of the larvnx 
which occur in early life are (1) catarrhal and (2) pseudo-membranous. 

Catarrhal laryngitis may be acute or chronic. 

Acute Laryngitis. — The pathological condition which is present in the 
acute form of laryngitis is a redness or hypersemia of the laryngeal mucous 
membrane, accompanied by more or less swelling and serous exudation. 
The cause of acute catarrhal laryngitis is often a simple extension of a 
catarrhal condition of the nose and pharynx to the larynx. ^lore rarely a 
catarrhal condition of the bronchi and trachea mav extend upward and 
involve the larynx. At times the condition appears to be the result of 
atmospheric changes and undue exposure to dampness and cold. The 
lumen of the larynx in infancy and in early childhood is so small that 
even a moderate swelling of the laryngeal mucous membrane may produce 
sufficient stenosis to give rise to marked obstructive symptoms. 

Symptoms. — The symptoms of acute laryngitis are a heightened tem- 
perature, 38.3°, 38.8°, 39.4° C. (101°, 102°^ 103° F.), and even higher, 
hoarseness, and cough. These symptoms, occurring in connection with a 
preceding rhinitis or pharyngitis, or arising from a primary inflammation 
of the larynx, may continue for a number of days without any more serious 
manifestations, and if the child is kept in an equable temperature the attack 
may pass off within a week. In some cases, however, another set of symp- 
toms may appear after the primary manifestations have lasted for a variable 
period. The child may have been as well as usual during the day, and 
may have been playing about. Towards the latter part of the day its voice 
may have become hoarser, but otherwise no especial symptoms may have 
arisen. The child, after being restless for a time, suddenly awakes, and 
springs up in bed frightened, often clutching at its throat as if it had a sen- 
sation of suffocation. The cough, which during the day was hoarse and 
somewhat metallic, is now loud and rasping. The child has dilRculty in 
breathing, amounting to orthopnoea, and its face is congested. These symp- 
toms continue for a variable period ; usually they last for only one or two 
hours, but rarely they may continue for many hours. In one very un- 
common case which was under my care the attack lasted for three or four 
weeks, clurino; which time it often seemed as thouoh suffocation was immi- 
nent. There was in this case no evidence of any lesion beyond a catarrhal 
laryngitis, and recovery finally took place. These attacks are partly due 
to obstruction in the larynx from the swollen mucous membrane, but are 
laro;elv the result of a neurosis due to a hio-hlv sensitive condition of the 
mucous membrane. On the following day the hoarseness may continue, 
but the child may seem bright and may play about as usual. It is very 
common for the attack to recur on the second night with greater severity, 
but in certain cases one attack terminates the disease, and after a variable 
period of days, the voice becoming clearer each day and the temperature re- 
turning to normal, the child recovers. Children who have once had attacks 
of this kind are liable to have a recurrence until thev orow older. 



952 PEDIATRICS. 

Diagnosis. — The diagnosis of acute catarrhal laryngitis is to be made 
from foreign bodies in the larynx, traumata, and membranous larjmgitis. 
The symptoms in the first two are not preceded by catarrhal symptoms 
elsewhere, which are almost always met with in catarrhal laryngitis. In a 
typical case of acute catarrhal laryngitis with suffocative symptoms the 
diagnosis is not difficult. The acute, sudden onset of the attack in the 
night, the loud, metallic cough, and the heightened temperature, are distinc- 
tive from the moderate temperature and the slow, progressive stenosis caused 
by the formation of a membrane in the larynx. 

Treatment. — The treatment of acute catarrhal laryngitis is to keep 
the child in a room of an equable temperature of about 20° to 21° C. 
(68° to 70° F.) until its temperature has become normal and the hoarseness 
has disappeared. I have also found that a few drops of wine of ipecac, 
given in the latter part of the afternoon and just as the child is going to 
sleep, are of benefit in preventing the spasmodic, obstructive symptoms 
which I have just described as occurring in the night. When the attack 
occurs in the night the symptoms of suffocation can be best relieved by a 
dose of from ten to fifteen drops of wine of ipecac, or an amount sufficient 
to nauseate slightly. An emetic will sometimes cut short an attack of this 
nature, but in many cases is not necessary. An amount of ipecac sufficient 
to nauseate slightly, but not to cause the child to vomit, will often so relax 
the spasm of the larynx that the attack will soon be relieved. In many 
cases, however, even if vomiting has been produced, the attack continues, 
and other measures for relief are required. In addition to the ipecac, mod- 
erate doses of tinctura opii camphorata may be given. An atmosphere of 
steam usually gives great relief to the spasm. 

Acute laryngitis is a self-limited disease, and one in which the prognosis 
is almost invariably good. In children who are very Aveak and debilitated 
the interference with their respiration may prove to be serious, but these 
cases are rare and should be treated with stimulants until the disease has 
run its course. The symptoms of acute catarrhal laryngitis are so terri- 
fying to the parents that the physician is often led to look upon the disease 
more seriously than is necessary. Many accidents have occurred from the 
improper management of the steam, from giving such emetics as turpeth 
mineral, and from the exhibition of strong drugs, the use of which is uncalled 
for. The necessity for operative measures rarely arises. 

Chronic Laryngitis. — A chronic form of laryngitis occurs in both 
infants and children. Syphilitic infants, as I have already told you, are at 
times affected by chronic laryngitis. It may also occur in tubercular dis- 
ease, but is not common. Where an acute laryngitis has occurred a number 
of times, or where an attack has been much prolonged by improper treat- 
ment, chronic laryngitis may result. In many of these cases the voice, on 
the slightest exposure to dampness- becomes hoarse, and this hoarseness, 
after a time, may be continuous. 

The treatment is to apply astringents to the pharynx, which is almost 



DISEASES OF THE LARYNX AND TRACHEA. 953 

universally involved, and to regulate the climatic surroundings of the child. 
Local applications to the larynx in these cases are seldom necessary. 

Pseudo-Membranous Laryngitis. — A pseudo-membrane in the larynx 
may be caused by the inhalation of irritating vapors, or by the inspiration 
of corrosive liquids. These accidents are so readily recognized that there is 
no difficulty in determining the cause of the pseudo-membrane in these 
cases. Treatment for the relief of the stenosis should be instituted at once. 
This consists in the application of cold and such soothing inhalations as 
3.75 c.c. (1 drachm) of compound tincture of benzoin in a quart of boiling 
water. The complicating oedema which is often present in these cases may 
require operative interference. 

The most common cause of pseudo-membranous laryngitis, and the one 
which probably in all cases produces it, is some form of micro-organism. 
These micro-organisms, as I have already stated in my lecture on diph- 
theria, may be of several varieties. Until it is proved not to be so, how- 
ever, pseudo-membranous laryngitis must be clinically looked upon as in- 
fectious and due to the Klebs Loeffler bacillus. I must again impress upon 
you the fact that a simple catarrhal inflammation localized in the larynx may 
be produced by the Klebs-Loeffler bacillus. Pseudo-membranous laryngitis 
may then, until further investigations prove the contrary, be defined as an 
infectious inflammation of the mucous membrane of the larynx accompanied 
by a pseudo-membranous exudation, which may be caused by a number of 
micro-organisms, of which, according to our present knowledge, the Klebs- 
Loeffler bacillus is the most common. 

I have described the symptoms, diagnosis, and treatment of pseudo- 
membranous laryngitis in a previous lecture (page 824), and shall, there- 
fore, refer you to what I then said. 

Some aid in the differential diagnosis of pseudo-membranous from acute 
catarrhal laryngitis can be obtained from the temperature, which in the latter 
is considerably raised, while in the former it is moderate and sometimes 
normal or subnormal. The slow course of a constitutional disease gradu- 
ally causing obstruction is significant of this infectious form of laryngitis. 

TRACHEA. — Pathological conditions of the trachea not connected with 
those of the air-passages above or below it are uncommon. The lesions of 
the trachea may be primary or secondary. In the latter they are merely an 
extension of the disease from the larynx or the bronchi, and do not play 
an especially significant part in the attack. The only primary disease of 
the trachea which is common in infancy and childhood is an acute inflam- 
mation occurring in its mucous lining. When this inflammatory condition 
is present, it produces an irritating cough which can usually be excited by 
gentle pressure over the trachea, — about the only method by which we can 
locate the disturbance. 

The treatment is to protect the child from an atmosphere which is either 
too hot or too cold, from high winds, and from dust. Douching the front 
of the neck with cold water several times during the day is also desirable. 



954 PEDIATRICS. 



IvKCTURE XLIX. 

DISEASES OF THE LUNGS. 

Bronchitis. — Broncho-Pneumonia. — Atelectasis. — Lobar Pneumonia. — Gan- 
grene.— Tuberculosis. — Pertussis. — Asthma. — Periodic Catarrh. 

LUNGrS. — The diseases which affect the lungs in infancy and childhood 
differ somewhat from the same diseases occurring in later life, on account 
of the differences which exist in the anatomical conditions at birth and 
during the early years of life, especially the first five. These differences I 
have described to you in previous lectures (pages 43 and 76). I then 
told you that the principal differences were that the bronchi occupied a 
relatively larger portion of the lung in the child than in the adult, that 
in the former the interstitial tissue was present in a larger amount, that 
the cavities of the air-vesicles were smaller, and that their walls were rela- 
tively thicker ; also that the epithelial cells lining the air- vesicles were 
very numerous. These cells in inflammation tend to rapid cell-division, 
which is one of the characteristics that mark the pneumonia of childhood. 
These anatomical differences are of great significance when any part of the 
lung is diseased, and tend to make a congested lung of much more serious 
import in the young child than in the adult. 1 shall not attempt to de- 
scribe to you all the various pathological conditions which may occur in the 
child's lungs, but shall restrict myself to those clinical groups of symptoms 
which represent the especial diseases. In order to do this I shall designate 
the disease according as the bronchi, the alveoli, or other parts of the lungs 
are most affected. You must remember that post-mortem examinations 
often show various lesions which during life were not represented by any 
definite symptoms, so that we cannot expect the clinical diagnosis to include 
entirely the pathological lesions. Beginning with the part of the lungs 
which is a direct continuation of tlie larynx and the trachea, I shall first 
speak of bronchitis. 

Bronchitis. — Bronchitis is often secondary to some other disease, or to 
a direct extension from an inflammatory condition of the upper air-passages. 
In a number of cases, however, the group of symptoms by which we deter- 
mine that bronchitis is present is so prominent from the very beginning of 
the attack that clinically we can describe a primary bronchitis. 

By bronchitis we mean an inflammation of both the large and the small 
bronchi, with the exception of the ultimate divisions which lead directly 
into the alveoli, and which probably are never affected without involving 
the alveoli also. The disease may be acute or chronic. 

The anatomical peculiarities of the mucous membrane lining the bron- 



DISEASES OF THE LUNGS. 955 

chial tubes — namely, the prominence of its capillaries and its comparatively 
loose connection to the muscular walls — render the bronchial mucous mem- 
brane peculiarly susceptible to congestion. Exposure to sudden atmospheric 
changes, especially humidity, appears to be of great etiological importance 
in the production of bronchitis. Any impurity of an irritating nature in 
the inspired air may in certain individuals result in an attack of bronchitis. 
A catarrhal inflammation of the upper air-passages is often followed by a 
similar inflammation of the bronchial mucous membrane. Bronchitis is 
of frequent occurrence in pertussis and measles. It is in children often a 
prominent symptom of typhoid fever, and is a frequent complication of pul- 
monary tuberculosis and epidemic influenza. There are also certain diseases 
of nutrition in which bronchitis frequently occurs. The most prominent 
of these is rhachitis, in which the complication of bronchitis is often of 
serious import. 

Acute Bronchitis. — Pathology. — The pathological conditions which 
are present in acute catarrhal bronchitis are, according to Delafield and 
Prudden, a congestion and swelling of the mucous membrane, and an arrest 
of the functions of the mucous glands. Later, the mucous glands resume 
their functions with increased activity, the congestion diminishes, there is an 
increased desquamation of epithelium, an increased formation of the deeper 
epithelial cells, a moderate emigration of white blood-cells, and sometimes 
the red blood-cells also escape through the vessels. The whole process is a 
superficial one, and does not produce any change in the w^alls of the bronchi 
beneath the mucous membrane, unless it has persisted for some time, when 
there may be a slight thickening of the walls. When the inflammation 
involves the smaller bronchi they may be occluded. The occlusion of the 
smaller bronchi may result in the collapse of the group of air-vesicles to 
which they lead, and thus will be produced areas of atelectasis, which may 
be further changed by inflammatory processes. The bronchial glands are 
frequently enlarged, even in mild attacks of bronchitis. 

I have here the section of a lung (Fig. 133, page 956), made by Nor- 
thrup, taken from a child, which shows the exudative inflammation of the 
bronchi which occurs in acute bronchitis. 

The specimen shows hyperplasia of the lymph-glands due to bronchitis. 
This condition is very commonly found in bronchitis, especially when it 
occurs in debilitated children. There is desquamation of the epithelium 
lining the bronchi, as well as a slight thickening of their walls. 

Symptoms. — The onset of acute bronchitis is usually mild, but I have 
seen in a debilitated infant a simple, uncomplicated bronchitis begin with 
a convulsion. The symptoms are very variable in their intensity, and are 
usually more acute and definite in a previously healtliy child than in 
debilitated children, in whom they are often subacute and of an insidious 
nature. In infants and young children the bronchitis is almost always 
preceded by a catarrhal condition of the upper air-jmssages. In the mild 
cases there is a heightening of the temperature, 37.7° to 38.3° C. (100° to 



956 



PEDIATRICS. 



]01° F.)j cough of greater or less severity, and a slight lessening of the 
appetite. On physical examination the pulmonary resonance is found to 
be normal. A few sibilant and sonorous rales are heard with especial fre- 
quency in the area between the scapula and the vertebral column. Moist 
rales may also be heard. In severe cases the children suffer from more or 
less discomfort, produced probably by the thoracic pain, although in young 
children the locality of the pain cannot, as a rule, be determined. The 
cough is hard and dry, the respirations may be slightly raised, and the 

Fig. 133. 




Br., bronchus ; Art., artery ; Lym. GL, lymph gland. 

pulse quickened. The children may appear quite sick for two or three 
days, and the temperature may rise as high as 38.8° or 39.1° C. (102° 
or 102.5° F.) ; but when this latter point is reached the onset of a broncho- 
pneumonia should be carefully watched for, especially if after from twenty- 
four to forty-eight hours the temperature does not fall to 37.7° or 38.3° 
C. (100° or 101° F.\ 

After a few days the severity of the symptoms lessens, the cough becomes 
looser, the rales gradually disappear, and under favorable conditions the 
symptoms subside entirely in a week or ten days. There is seldom any 
expectoration in children under six or seven years. In the more severe 
cases the rales are more numerous than in the mild form of the disease, but 
are of the same character. In the course of some cases of bronchitis a tem- 
porary localized diminution or even absence of the respiratory sound may 
result from the occlusion of a bronchus. This is especially common in 
infants, and ordinarily is not accompanied by a change in the percussion- 
sound. This form of bronchitis is the one which affects the larger and 
the medium-sized bronchi. 



DISEASES OF THE LUNGS. 957 

There is no characteristic temperature in bronchitis. As a rule, it is 
moderate, 37.2° to 38.3° C. (99° to 101° F.), but it varies greatly accord- 
ing to the individual and to the degree of nervous excitement. 

Diagnosis. — The diagnosis of the ordinary cases of acute bronchitis, 
where only the large- and medium-sized bronchi are affected, is not difficult, 
the only disease for which it is likely to be mistaken being broncho-pneu- 
monia. In this latter disease the greater severity of the symptoms and the 
higher temperature will usually show its presence, even though the physical 
signs may be only those which I have described as occurring in bronchitis. 
In the more severe forms of bronchitis it is sometimes exceedingly difficult 
to make the differential diagnosis from broncho-pneumonia. If, however, 
the temperature, after three or four days, remains high, and rises to 39.1° 
or 39.4° C. (102.5° or 103° F.), with marked remissions and exacerbations, 
the diagnosis becomes doubtful, and in these cases we should strongly suspect 
that a broncho-pneumonia has arisen as a complication. We must, how- 
ever, remember that in certain cases of broncho -pneumonia the temperature 
may be as moderate as in acute bronchitis, and we must therefore rely on a 
combination of symptoms rather than on any one symptom or sign. An 
important point in the differential diagnosis between bronchitis and broncho- 
pneumonia is that the physical signs in the former are much more frequently 
found in all parts of the thorax, while in the latter circumscribed groups of 
rales are often detected in different parts of the lungs. The rales in them- 
selves, however, are not distinctive, as the rales in broncho-pneumonia are 
mostly those of the accompanying bronchitis. Although the physical signs 
of duluess and bronchial respiration are conclusive evidences that the case 
is not one of bronchitis alone, yet an absence of these signs does not justify 
us in excluding broncho-pneumonia. Where the dyspnoea, general prostra- 
tion, and restlessness are slight and the temperature moderate, the case is 
likely to be one of bronchitis, while if these symptoms are marked, and are 
combined Avith cyanosis, dilatation of the alse nasi, and a higher tempera- 
ture, at least a provisional diagnosis of broncho-pneumonia should be made. 
In some cases the differential diagnosis will also have to be made from the 
onset of a pleuritis or of a lobar pneumonia, but the moderate temperature 
and respirations, the normal percussion-sounds, and the diffuse bilateral rales 
in bronchitis usually make the diagnosis from these diseases quite evident. 

Prognosis. — The prognosis, where no complication arises and the child 
is previously healthy, is good. In debilitated children, and especially where 
rhachitis is present, even a mild form of bronchitis may prove to be serious, 
on account of the danger of a complicating broncho-pneumonia, and in these 
cases the prognosis is much more unfavorable. 

Treatment. — The treatment of acute bronchitis is essentially hygienic. 
The child should be confined to a warm, well -ventilated room which has a 
sunny exposure, and which is heated by an open fire to a tem])erature of about 
20° to 21.1° C. (68° to 70° F.). A few drops of wine of ipecac should be 
given if the cough is unusually dry, and to this a few drops of tinctura opii 



958 PEDIATRICS.. 

camphorata may be added if the patient is excessively nervous. These reme- 
dies are all that will usually be needed in an attack of acute bronchitis. 
Where a rhachitic child or one who is much debilitated is attacked by the 
disease, especial care must be taken to support its strength by stimulants 
and food. 

Besides the acute bronchitis which I have just described, I have met 
with a class of cases which are extremely rare, but which, apparently, are in- 
stances of an exacerbation of an ordinary bronchitis through the involvement 
of the smaller bronchi, not the terminal ones. I have seen only six of these 
cases. These, from their clinical history, seem to have been cases of bron- 
chitis rather than of broncho-pneumonia. I speak of them separately, as the 
symptoms differ somewhat from those of an ordinary bronchitis. This 
form of bronchitis has no connection with what was formerly erroneously 
called capillary bronchitis, but which is now well known to be only an 
early stage of broncho-pneumonia. This form of bronchitis in my cases 
has commonly occurred in infants in the first two years of life, though I 
have met with it as late as the third year. The cause, so far as could be 
ascertained, was the same as in an ordinary bronchitis, a catarrhal condition 
of the upper air-passages usually preceding the attack. The onset of the 
disease was rapid, and the symptoms soon became very severe. The tem- 
perature was, as a rule, moderately raised, 37.7° to 38.3° C. (100° to 101° 
F.). The cough was continuous, and dyspnoea, with more or less cyanosis, 
rapidly developed. An examination showed normal resonance through the 
whole thorax, and fine moist rales. The respirations were rapid, the pulse 
was quick, and all the symptoms were of a violent and suffocative nature. 
The infants were much distressed, and were unwilling to be laid down. 
After from twenty-four to forty-eight hours the symptoms grew less severe, 
the temperature became normal or was only slightly raised, and the fine 
moist rales were replaced by coarse moist rales and the sibilant and sonorous 
rales of an ordinary bronchitis of the larger and the medium-sized bronchi. 

In the early hours and days of the disease, when the symptoms are at 
their height, and if the infant is weak and debilitated, the prognosis is 
bad. If, however, the first few days are passed in safety, recovery almost 
invariably takes place. 

This form of bronchitis is to be differentiated from broncho-pneumonia. 
The temperature, instead of remaining high and having the remissions of a 
broncho-pneumonia, soon falls so as to correspond to that of an ordinary 
bronchitis. The physical signs are those of bronchitis rather than of pneu- 
monia, and the rapid recovery of the infant with the common symptoms of 
an ordinary bronchitis, rather than with the prolonged and characteristic 
symptoms of a broncho-pneumonia, verifies the diagnosis of an inflamma- 
tion of the smaller bronchi. 

These cases may be complicated with broncho-pneumonia, as are the 
ordinary cases of bronchitis. 

The treatment of this class of cases is very important, as death from 



DISEASES OF THE LUNGS. 



959 



exhaustion is liable to occur at any moment. The extreme congestion of 
the blood-vessels of the smaller bronchi may in some cases occlude the air- 




Acute bronchitis. Female, :> montlit^ old. 



spaces, and areas of atelectasis may result. The indications for treatment 
are to oxygenate the blood, to support the strength until the disease has run 



960 



PEDIATRICS. 



its course, and to prevent the infant from falling into a comatose condition. 
The treatment, therefore, is the administration of oxygen, the use of stimu- 
lants, consisting of aromatic spirit of ammonia alternating with brandy, and 
change of the position of the infant from time to time. 

Here is an infant (Case 459, page 959), three months old, who has for the past few 
days had an attack of acute bronchitis, characterized by a paroxysmal, dry cough, slightly 
accelerated respirations and pulse, and a moderate temperature varying from 37.7° to 38.3° 
C. (100° to 101° r.). 

The percussion of the chest has been normal, and there have been some sonorous and 
sibilant rales, with a few coarse moist rales heard on both sides of the chest. Early this 
morning the infant was attacked with excessive dyspnoea and cyanosis. Its pulse rose from 
120 to 180, its respirations from 30 to 70, and its temperature from 37.7° C. to 39.1° C. 
(100° F. to 102.5° F.). An examination of the chest showed normal resonance and fine 
moist rales throughout both lungs. It has been very restless, refuses to take its food, and 
evidently wishes not to be laid down in its bed, but to be carried about. It is being treated 
with alternate doses of aromatic spirit of ammonia and brandy every half-hour. The 
physical signs are those of a diffuse bronchitis of the smaller bronchi, which you see I have 
indicated by small black spots painted on the front and back of the chest. 

(Subsequent history.) After twenty-four hours the temperature fell to 38° C. (100.5° 
F.), the pulse to 150, and the respirations to 44. The fine rales were replaced by the 
ordinary coarse rales of a bronchitis, and the infant rapidly recovered. 

The symptoms and course of all these cases are very similar, so that I 
shall speak only of one other child, whom I saw in consultation with Dr. 
Horace Marion, of Brighton. 

CHART 82. 





Daijs of Disease. 


n 


IT. 


1 


2 


3 


4 


5 


6 


7 


8 


c. 


4 07° 
106° 
105° 
104 
103° 
102° 
101° 
100° 
99° 

NORMAL 
TEMP. 

98 

97° 

96° 
95° 


M E 


M E 


M E 


ME 


ME 


M E 


ME 


ME 


41.6'° 

41.1° 

40.5° 

40.0° 

39.4° 

38.8° 

38.3° 

37.7° 

37.2° 
37.0° 
36.6° 

36.1° 

35.5° 
35.0° 






































































































/ 
















/ 


\ 










^ 


^^ 







^ 


^ 



























































Acute bronchitis— exacerbation. Male, 7 months old. 

A male (Case 460), seven months old, and previously healthy, for two days had a slight 
cough, with a few sonorous rales in the chest and a temperature varying from 36.6° to 37.2° 
C. (98° to 99° F.). On the third day of the attack he was suddenly seized with increased 
cough, dyspnoea, cyanosis, respirations of 70, a pulse of 160, and a temperature of 38.3° C. 
(101° F.). An examination of the chest showed normal resonance and fine moist ralet 



DISEASES OF THE LUNGS. 961 

throughout both lungs. The infant was treated with aromatic spirit of ammonia and brandy 
in alternate doses. On the following day the temperature fell to 37° C. (98.6° F.), and the 
fine rales were replaced by coarse rales and sonorous rales. The bronchitis lasted for a few 
days, and the infant then recovered entirely. 

Here is the chart (Chart 32, page 960) which shows the sudden rise of temperature. 

Chronic Bronchitis. — Chronic bronchitis may result from a series of 
attacks of acute bronchitis, or from a number of other causes. Among these 
may be mentioned various affections of the lungs, such diseases connected 
with malnutrition as rhachitis, and prolonged attacks of pertussis. 

The pathological conditions occurring in chronic bronchitis vary greatly 
in degree, and the lesions found at the post-mortem examination are often 
slight in comparison with the severity of the symptoms during life. In 
most cases there is a considerable production of mucus, pus, and serum. In 
cases which have lasted for a long time, in addition to the inflammatory 
products affecting the walls of the bronchi there may be dilatation of one 
or more bronchi, and the muscular coat may be thickened or thinned. 
Emphysema may also result. 

The symptoms of chronic bronchitis are very much the same as those 
of acute bronchitis, except that the temperature is not so apt to be 
heightened, while the general symptoms of malaise, anorexia, and loss of 
weight are more prominent. In severe and prolonged cases where emphy- 
sema is present, the thorax may assume the position of full inspiration, the 
ribs being permanently raised and the antero-posterior diameter of the chest 
increased. The physical signs are the same as in acute bronchitis, so far as 
the rales are concerned. The resonance is usually normal except where the 
chronic process has produced emphysema, in which case there will be areas 
of hyper-resonance often associated with a tympanitic tone. Occasionally 
atelectasis of considerable areas of the lungs may take place, with a resulting 
lessening of the respiratory sound. This occurrence may in some cases 
prove to be serious, but in others the accompanying symptoms are mild, and 
the alveoli may again return to their normal degree of inflation. 

The differential diagnosis is to be made from chronic affections of the 
lungs in which the thickening of the interstitial tissue has taken place with 
a resulting lessening of resonance, and from the condition in which the 
bronchi are dilated. In the latter case there are accompanying symptoms 
of a profuse exudation of purulent matter. 

There is one form of bronchitis which from its duration may be called 
chronic, and yet which from the very slight degree of constitutional symp- 
toms that accompany it corresponds rather to a subacute affection. In these 
cases, which usually occur in infancy and in early childhood, the cliild often 
appears quite well, but for long periods of weeks, or whenever it is exposed 
to a damp atmosphere, a loud wheezing will be heard in the chest. Auscul- 
tation will reveal the presence of sonorous rales everywhere, and in this 
variety, as well as in other forms of chronic bronchitis, a roughened sensa- 
tion may sometimes be felt on palpation during respiration. 

61 



962 PEDIATRICS. 

The prognosis of chronic bronchitis varies according to the cause. 
Where it is secondary to disease of some other organ, it depends entirely 
upon the prognosis of that disease. In rhachitic children the prognosis is 
unfavorable, and in them a broncho-pneumonia is especially liable to 
develop, with a fatal issue. Cases of chronic bronchitis are also liable to be 
invaded by the bacillus tuberculosis. In cases which are the result of acute 
bronchitis in individuals otherwise healthy, the prognosis is favorable, pro- 
vided the proper treatment can be carried out. As emphysema in chronic 
bronchitis is rare in children in comparison with adults, the chances for 
recovery in the former are correspondingly good. 

The treatment of chronic bronchitis is essentially climatic. The chil- 
dren should be kept in a warm dry climate for some months after the bron- 
chitis has entirely disappeared. Especial care should be taken that the 
child is suitably protected by flannel undergarments. Where other treat- 
ment is required, as a rule, tonics will prove of more benefit than the drugs 
which are usually administered for their direct effect upon the bronchial 
mucous membrane. 

Fibrinous Bronchitis. — During the course of what may appear to be 
an ordinary bronchitis, in rare instances a fibrinous form of bronchitis has 
been met with. In this variety masses of fibrin in the bronchi form casts 
of various extent according to the number of the bronchi which are affected. 

The disease may run a short course of days or weeks, but is usually 
chronic and may last for years. The paroxysms may also be periodic. 

The diagnosis can be made only when portions of the casts have been 
expectorated. 

The treatment is chiefly by the inhalation of steam from lime water, 
and by supporting the strength with proper nourishment and stimulants 
until the disease has run its course. 

Broncho-Pneumonia. — Broncho-pneumonia is an affection of the lung 
characterized by an inflammation of the walls of the terminal bronchi and 
of the alveoli. The disease may be acute or chronic. It may occur at any 
age, but is the most common and fatal form of inflammation of the lung 
during the first five years of life, and is much more fatal than lobar pneu- 
monia at this period. During this early period, and especially during the 
first two or three years of life, the lung, from its embryonic type, is more 
frequently subject to the form of inflammation occurring in broncho-pneu- 
monia than at a later and more developed period. The disease is usually 
secondary to bronchitis, and commonly occurs in connection with measles, 
scarlet fever, pertussis, and diphtheria. Broncho-pneumonia is also a very 
important disease, not only as grave in itself, but also because it is so fre- 
quently followed by tuberculosis. 

Etiology. — A prominent predisposing cause of broncho-pneumonia is 
age, and where pneumonia occurs in a child under five years of age it is 
usually in the form of broncho-pneumonia. This is due principally, as I 
have already stated, to the anatomical conditions met with in early life. 



DISEASES OF THE LUNGS. 



963 



Children who are weak or debilitated by previous diseases show a predis- 
position to broncho-pneumonia, and it therefore frequently arises in the 
course of tuberculosis, -chronic gastro-enteric diseases, and rhachitis. Those 
seasons of the year which are marked by cold, moisture, and variations of 
temperature especially predispose to the development of broncho-pneumonia. 
All these conditions, however, in all probability merely prepare the way for 
the entrance of certain germs which produce the disease. WJiat these micro- 
organisms are is still uncertain, as it is known that a number of different 
organisms can produce the disease. The origin of broncho-pneumonia from 
intestinal infection must also be considered. (Sevestre.) 



Fig. 134. 




Acute broncho-pneumonia involving different areas of the lung. A, consolidated lung-tissue ; B, dilated 
bronchus. (Warren Museum, Harvard University ) 

Pathology. — In broncho-pneumonia the inflammatory process affects 
the walls of the smaller and terminal bronchi, which become thickened and 
markedly infiltrated with cells. The inflammatory process then extends 
through the walls of the bronchi to the surrounding air-vesicles as well as 
to the terminal ones. In this way centres of consolidation are formed in 



964 



PEDIATRICS. 



different parts of the lung. The course of this inflammation varies in its 
rapidity, at times attacking only a small portion of the lung, and again 
being more diffuse in its onset and gradually invading large areas. The 
lesions are irregular in their distribution, and usually occur in both lungs. 
They are at times so extensive as to involve a whole lobe, but, as has been 
stated by Northrup, whatever the extent of hepatization, whatever the time 
occupied in its course, and whatever the post-mortem appearances, the essen- 
tial lesion is an inflammation of the walls of the terminal bronchi and of 
the adjacent alveoli. 

This lung (Fig. 134, page 963), taken from a young child, presents the 
macroscopic lesions of broncho-pneumonia. 

You will notice that the areas of consolidation surround the bronchi, 
and that this bronchus (B) is markedly dilated. 

This section of a lung (Fig. 135), made by Northrup, was taken from 
an infant sixteen months old, in whom the broncho-pneumonia was a com- 
plication of measles. It shows the early pathological lesions of broncho- 
pneumonia. 

Fig. 135. 




iWfm 



Broncho-pneumonia complicatinf,' mcasleR. 
chiole; Ji.T. 



Early stage. C. L. T., consolidated lung tissue ; Br., bron- 
Dmphyseinatous lung tissue. 



You will notice that in one of the lobules there are two bronchioles 
(Br.) with infiltrated walls and pus within them. They are also filled with 
exudation, and the lumen of each is almost entirely occluded. A portion 



DISEASES OF THE LUNGS. 



965 



of a neighboring lobule is consolidated (C. L. T.). A considerable portion 
of the lung tissue (L. T.) in the section is, as you see, normal or emphy- 
sematous. 

Here is another section (Fig. 136), made by Northrup, illustrating the 
broncho-pneumonia which follows a diphtheria descending from the upper 
air-passages, and which may occur in any acute infectious disease. It shows 
the typical lesion of broncho-pneumonia. 




Broncho-pneumonia secondary to diphtheria. 

In the bronchus, which you see enlarges in the middle of the section, the 
lining mucous membrance is hanging in shreds into its lumen. The walls 
of the bronchus are densely infiltrated, and the contiguous alveoli are filled 
with exudation to a greater or less extent and are consolidated by it. This 
section Avas taken from the lung of a child three years old who during an 
attack of scarlet fever developed diphtheria of the larynx. The diphtheritic 
process descended later into the bronchi. 

Here is another section (Fig. 137, page 966) taken from the lung of the 
same child, but showing the tissue relatively less affected. 

Many of the consolidated alveoli contain free blood-cells. The bron- 
chial wall (Br.) is infiltrated and almost entirely denuded of its lining 
membrane. 

These smaller bronchi are surrounded by zones of intense congestion 
and infiltration. When the inflammation is intense and is accompanied by 
abundant secretion these bronchi frequently become dilated. This dila- 
tation is associated with a weakened condition of the bronchial walls and 
with an abundant secretion. These dilatations probably, according to the 



966 



PEDIATRICS. 



observations of Xorthrup, wholly disappear on the recovery of the patient. 
As has already been described in the pathology of bronchitis, the bronchial 
lymph-glands are always enlarged in broncho-pneumonia, and there may be 
fibrin on the pulmonary pleura. According to Delafield, in the zones of 
peribronchitic pneumonia the walls of the air-vesicles are thickened or 
swollen, either with or without some cellular infiltration, and the cavities of 
the air-vesicles are filled with epithelial cells and pus-cells, with fibrin and 




Broncho-pneumonia secondary to diphtheria. Br., bronchus ; C. L. T., consolidated lung-tissue ; 
N. L. T., lung-tissue nearly normal ; Art., artery. 

red blood-corpuscles in varying proportion and amount. Fibrin when 
present is only in small , quantities, and often is absent altogether. The 
capillaries in the walls of the vesicles are congested and prominent. The 
portions of lung which are not hepatized are congested and oedematous. 
The cavities of the air- vesicles are diminished by the enlarged capillaries 
and the swollen vesicular epithelium. 

In addition to the other lesions \vhich I have just described, areas of 
atelectasis are frequently found in broncho-pneumonia. This atelectasis is 
usually produced by mechanical causes, such as obstruction by pus or tena- 
cious mucus. It may also arise as a result of enfeebled respiratory power. 
The blood-vessels become dilated, the walls of the alveoli partially collapse, 
the residual air is absorbed, and an exudation of serum with proliferative 



DISEASES OF THE LU^^GS. 967 

cells and leucocytes takes its place. The atelectasis is commonly symmet- 
rical, affecting the posterior margin of both lower lobes of the lung, but it 
may also appear in irregular scattered areas in the posterior portions of 
the upper lobes (Northrup). It may occur either during the acute stage of 
the inflammation or later when the pneumonia has become chronic. There 
are no distinct stages in the pathology of broncho-pneumonia which corre- 
spond to those of lobar pneumonia. According to Xorthrup, broncho-pneu- 
monia develops by the irregular invasion of successive portions of the 
lungs, and the process resolves in like manner. The different consolidated 
areas in the same lung may often show all the stages. The mottled ap- 
pearance which is so often noticed macroscopically in these lungs may be 
caused by the presence of lobules of gray and red hepatization lying side by 
side. Of these inflammatory products the fibrin disintegrates quickly, and is 
therefore absorbed more rapidly than the cellular elements, which do not dis- 
integrate so readily. In lobar pneumonia, therefore, absorption takes place 
sooner than it does in broncho-pneumonia, where the products of inflamma- 
tion are mostly cellular and resolution and absorption are naturally slow. 

Instead of the gradual disappearance of the various pathological lesions 
the pneumonia may persist. This persistent form of the disease may, 
according to Delafield and Prudden, follow a single attack of acute broncho- 
pneumonia, or there may be several acute attacks before the chronic condi- 
tion becomes evident, and the course of the disease may thus vary in different 
cases. When this persistent broncho-pneumonia occurs, the proliferative 
cells take part in the formation of new^ connective tissue, and in this way 
persistent thickening is caused. The alveolar walls of certain portions may 
become similarly thickened. The walls of the bronchi and their surround- 
ing tissue are especially subject to a persistent thickening and a formation 
of new connective tissue constituting chronic broncho-pneumonia and peri- 
bronchitis. The bronchi already dilated become still more enlarged by the 
contraction of the cicatricial tissue surrounding them. The uneven contrac- 
tion of this new tissue, together with the pressure within the tubes facilitated 
by a weakened condition of the walls, allows of saccular as well as of fusi- 
form dilatation of the bronchi. The epithelial cells of the dilated bronchi 
proliferate, and, falling from the bronchial walls, mix with the bronchial 
secretion. The remaining epithelium is swollen and loose. The lesions of 
chronic broncho-pneumonia are frequently associated with tuberculosis of 
the bronchial glands and with other tubercular lesions. 

In connection with the pathological lesions occurring in chronic broncho- 
pneumonia a condition called fibroid phthisis has in very rare cases been 
noticed in cliildren. The lesions which represent fibroid phthisis are mani- 
fested in the presence of connective tissue in the lung, with a corresponding 
destruction of the true parenchyma. These changes are usually unilateral, 
and should not be considered as representing a disease, since they merely 
occur in the course of various chronic pulmonary affections, among which 
are tuberculosis and chronic broncho-pneumonia. 



968 PEDIATRICS. 

Under this microscope (Fig. 138) you will see a section of the lung, 
made by Dr. Northrup, taken from a young child with chronic broncho- 
pneumonia. 

Fig. 138. 




Chronic broncho-pneumonia. N. L. T., normal lung-tissue ; C. L. T., consolidated lung-tissue ; 
Br., bronchi, some of them dilated. 

You will notice the areas of consolidated lung (C. L. T., peribrouchitis) 
around the bronchi, which are dilated (bronchiectasis). You will also ob- 
serve that there are areas of normal lung-tissue (I^. L. T.). 

Under this second microscope (Fig. 139) is a section, also made by Dr. 
Northrup, taken from a lung with chronic broncho-pneumonia in which the 
process has advanced still further than in the other. 

In the middle of the specimen you will see a dilated bronchus with a 
section of a blood-vessel just below ito There is considerable connective- 
tissue formation about both. Here you see that the process of a peribron- 
chitic pneumonia has gone further than in the other specimen (Fig. 138), 
and that there is, in addition to the dilated bronchi with the surrounding 
cellular infiltration, a tendency to the formation of connective tissue in the 
interlobular septa. This is the form of chronic broncho-pneumonia which 
is sometimes called interstitial pneumonia, and is usually characterized by 
a long course and delayed recovery. 

A frequent lesion which occurs in the course of broncho-pneumonia is 
emphysema. According to Northrup, it is usually vesicular and situated in 



DISEASES OF THE LUNGS. 969 

the anterior portion of the upper lobes. It is due to the diminished amount 
of air-capacity^ together with the violent introduction of air into the chest 
caused by dyspnoea and coughing. This distention of the air-vesicles is 
supposed usually to disappear with the subsidence of the lesion which is 
causing the emphysema. Emphysema, both of the vesicular and of the 
interstitial variety^ most commonly occurs in the pneumonia which follows 
pertussis. 

Fig. 139. 




Chronic broncho-pneumonia. Br. dl., dilated bronchus ; Th. L. T., thickened lung-tissue ; 
Br. Pm., broncho-pneimionia. 

The interstitial variety may exist in the form of superficial sacs formed 
by the rupture of air-vesicles beneath lifting the pleura, or it may extend 
between the lobules in V-shaped tracts from the anterior edge of the upper 
lobe even to the root of the lung. 

Symptoms. — The symptoms of broncho-pneumonia vary greatly, owing 
to the many different lesions which commonly occur in the disease and which 
by their greater or less severity make its course exceedingly irregular. In 
so many instances is the broncho-pneumonia secondary to some other disease 
that the symptoms are necessarily modified by those of the initial afi^ection. 
Thus, where broncho-pneumonia arises in the course of diphtheria, the 
symptoms are often obscured by the severity of the general symptoms of 
the diphtheria. Where broncho-pneumonia is secondary to measles and to 
pertussis, although at times its onset is difficult to detect, yet, as a rule, the 



970 PEDIATEICS. 

quick respirations, the marked and continuous rise of temperature, and the 
evident exacerbation in the severity of the pulmonary symptoms, usually 
permit a diagnosis to be made even before the physical signs have become 
prominent. Its onset, however, in measles is, as a rule, rapid, while in 
pertussis it is slow and insidious. 

The group of symptoms which characterizes a broncho-pneumonia arising 
during the course of bronchitis is somewhat more definite. In place of the 
moderate temperature and the absence of signs of serious disease which are 
usually met with in the course of an ordinary bronchitis, when broncho- 
pneumonia supervenes the temperature rises, the pulse and respirations are 
quickened, the alse nasi dilate, there is more or less cyanosis, the cough 
becomes more frequent and painful, and the general aspect of the patient is 
that of one suffering from an affection of a severe type. 

The temperature in broncho-pneumonia varies greatly, according to the 
extent and severity of the lesions. Corresponding to the intensity of the 
pneumonic onset, or to the especial disease which it complicates, the temper- 
ature rises rapidly or slowly and insidiously. The most common course in 
mild cases with gradual onset and terminating in recovery is for the tem- 
perature to rise gradually to 39.4° or 40° C. (103° or 104° F.), then to 
have a morning remission of three or four degrees for a number of days, and 
then to fall irregularly by lysis. A crisis is very rare in broncho-pneu- 
monia, but sometimes occurs. Although the remissions in the temperature 
during the active stage of the disease are often quite marked, yet, as a rule, 
the temperature does not at this time fall to the normal. This is of service 
in differentiating certain cases of broncho-pneumonia, as well as lobar pneu- 
monia, from malaria. Occasionally the temperature is reversed, the highest 
point being reached in the morning. This is rare, and is of no especial sig- 
nificance. Where the temperature instead of remitting remains high and 
steadily rises, the disease, as a rule, soon terminates fatally. Instead of the 
continued high temperature which occurs so often in fatal cases, a low tem- 
perature of only a few degrees above normal is sometimes met with, usually 
where the vitality is low and the power of reaction slight. The duration of 
the heightened temperature is very variable in broncho-pneumonia, and may 
last for a number of days or for weeks without the necessary result of the 
grave lesions of a more chronic process. 

The pulse and respiration, though quickened, vary according to the 
severity of the disease and also according to the degree of nervous excite- 
ment. This latter is a very important element to be considered in deter- 
mining the gravity of their rate. The pulse is at times very rapid, 160-180, 
and even higher ; it usually varies from 130 to 150 or 160 ; though regular 
and full at first, it becomes weak and sometimes irregular as the disease 
progresses, and is very apt to remain rapid even after the temperature has 
declined and convalescence has been established. The respirations may be 
quickened by an unusually high temperature, but depend mostly on the 
extent of the involvement of the alveoli. They vary from 50 to 80, but 



DISEASES OF THE LUNGS. 971 

they may be even higher, and are accompanied by dilatation of the alse nasi. 
The respiration often shows a pause after inspiration instead of after expi- 
ration, as occurs in normal respiration, and is usually accompanied bv an 
expiratory moan. 

This sign, however, is not characteristic of broncho-pneumonia, as it may 
occur in lobar pneumonia and in various atiections where the circulation is 
interfered with and where respiration is painful. In like manner the dilata- 
tion of the alse nasi may occiu- in any disease accompanied by a heightened 
temperature and nervous excitement. Temporary exacerbations and changes 
in the rhythm of respiration are quite common in broncho-pneumonia, and 
in some cases a Cheyne-Stokes type of respiration has been noticed. This 
sign is usually one of grave import. Recession of the epigastrium and of 
the intercostal spaces commonly occurs in broncho-pneumonia, and varies 
according to the severity of the pulmonary lesions. In infants painfiil 
respiration is shown by a frown rather than by crying, while in young 
children it is shown by their whimpering and suppressed cries. 

The physical signs of broncho-pneumonia are almost entirely those 
of the accompanying bronchitis, but in typical cases they correspond to the 
various pathological lesions which I have just described. According as 
larger or smaller areas of the lung are involved, corresponding areas of 
dulness on percussion may be found, provided these areas are sufficiently 
extensive not to be masked by other resonant portions of the lungs. They 
can, as a rule, be detected best by very light percussion. These areas of 
dulness are usually bilateral and of somewhat varied extent, though, as I 
have already stated, an entire lobe may in rare instances be sufficiently 
involved by the broncho-pneumonic process to produce very extensive areas 
of dulness. Over the area of dulness bronchial respiration, and in some 
cases increased vocal resonance and fremitus, may be found. On ausculta- 
tion moist rales of all sizes may be heard all over the lungs, or, as is more 
usual, in circumscribed areas. 

A symptom which occurs Cjuite commonly in broncho-pneiunonia is 
cyanosis. This may not only arise from the interference with the oxygena- 
tion of the blood from the lesions involving the air-vesicles, but may also be 
produced by a temporary atelectasis of certain portions of the lungs. The 
cyanosis is often accompanied by attacks of dyspnoea. When these symp- 
toms result from atelectasis, the temperature, as a rule, does not rise, but may 
even be somewhat reduced, and areas of dulness may be detected on percus- 
sion. During these paroxysms the skin is often cold and moist. When the 
cause of the atelectasis, whether it be obstruction by plugs of mucus or pus 
or temporary exhaustion of the contractile powers of certain portions of the 
lungs, has been removed, the cyanosis and dyspnoea pass away and the 
general symptoms improve. These symptoms may arise at various periods 
during the course of broncho-pneumonia, and unless the atelectasis passes 
off within a few days a fatal issue is very apt to result. 

Well-marked physical signs, especially dulness on percussion, are usually 



972 PEDIATRICS. 

found at the bases of both lungs behind, and also between the scapulae and 
the vertebral column. The earliest changes, however, in percussion and 
auscultation are often first detected in the highest part of the axilla. These 
signs of consolidation are rarely found in the early days of the disease, 
when the bronchitic signs are usually all that can be detected. The physical 
signs are markedly modified when atelectasis or emphysema is present. 

In cases which recover, resolution takes place slowly and the lung 
gradually returns to the normal condition. Great weakness and prostration 
often last for a long time. Relapses are quite common. 

Complications. — Pleurisy of a light grade is not an uncommon com- 
plication of broncho-pneumonia. Abscess and gangrene sometimes, though 
very rarely, arise. A case of the latter occurred at the Boston Children's 
Hospital in the service of Dr. Morrill. 

A very frequent and important complication of broncho-pneumonia is 
tuberculosis. 

In certain cases of the fulminant type of broncho-pneumonia the post- 
mortem examinations show extensive deposits of miliary tubercle, which in 
these cases is the cause of the accompanying acute inflammation. This con- 
dition is called tubercular broncho-pneumonia. 

A frequent, short, hacking, and painful cough is a constant symptom 
from the beginning of the disease, and even after resolution has taken 
place this may continue for a long period. Infants and young children, 
even up to the age of seven or eight years, have often not learned to ex- 
pectorate, so that we cannot, as in adults, judge of the character of the 
sputum. When the sputum is seen it corresponds to the pathological exu- 
dation which I have just described when speaking of the pathology of the 
disease. Vomiting is at times met with, and diarrhoea is not uncommon. 
In certain cases disturbance of the gastro-enteric tract is present from the 
very beginning, and the intestinal disease is apparently as important a 
feature of the attack as the pulmonary part. As the attack progresses 
the child loses much in weight, the face often looks pinched, and at times 
during the height of the disease there is a certain amount of delirium, 
which in combination with other grave symptoms, such as uncontrollable 
diarrhoea and a depressed temperature, is a serious symptom. 

Diagnosis. — The diagnosis of broncho-pneumonia should first be made 
from the bronchitis which ordinarily accompanies it. This has already 
been sufficiently referred to in speaking of the diagnosis of bronchitis. 

The differential dias^nosis between the non-tubercular and the tubercular 
forms of broncho-pneumonia is important, but can rarely be made in the 
early stages of the disease, as the lesions are the same, and a bacteriological 
examination of the sputum in these cases can seldom be obtained. 

The disease which should be especially considered in making the diag- 
nosis of broncho-pneumonia is lobar pneumonia. The two diseases are per- 
fectly distinct, in onset, course, duration, and termination, and can best be 
described when I speak of the diagnosis of lobar pneumonia (page 985). 



DISEASES OF THE LUNGS. 973 

Prognosis. — Age is a very important factor in the prognosis of bron- 
cho-pneumonia. As Morrill has shown by a carefully prepared table, a 
large majority of the fatal cases of broncho-pneumonia occurs in the first 
two years of life. The prognosis varies according to the disease in the 
course of which it occurs. It is most grave when it occurs in pertussis, 
especially in infants, and the younger the child the more fatal the disease. 
Next to pertussis, the gravity of the prognosis is greatest in measles and 
diphtheria. When it occurs in such diseases as rhachitis and tuberculosis, 
or where the individual has not been well cared for, the prognosis is also 
very unfavorable. I have already referred to the temperature as a prog- 
nostic sign in broncho-pneumonia. According to Holt's observations, the 
highest mortality occurs among the cases of shortest duration, and the 
disease is universally fatal when its duration is shorter than four days. 
After this early period of danger is passed the prognosis becomes much 
more favorable, the lowest death-rate in Holt's cases being met with in 
cases terminating in from eight to fourteen days. When the disease lasts 
for more than two weeks the chances of recovery are lessened every day 
that the temperature remains raised. The cases in which there is a very 
high temperature, 41.1° C. (106° F.), are usually fatal. Where the disease 
is protracted, death generally occurs from exhaustion. 

Treatment. — The treatment of broncho-pneumonia is that of the 
special disease to which it is secondary. The strength should be carefully 
supported from the time that the disease is first detected until convalescence 
has been completely established. The patient should be carefully nursed, as 
the nursing is the most important part of the treatment of broncho-pneu- 
monia and requires much judgment and intelligence. The atmosphere of the 
room should be equable, the temperature from 20° to 21.1° C. (68° to 70° 
F.), and especial attention should be paid to the ventilation. The heat and 
ventilation obtained from an open wood fire are especially valuable. As 
few drugs as possible should be given, since there is no drug which will cut 
short the disease, and most of the drugs commonly used in the treatment 
of pulmonary affections are, as a rule, of more harm than benefit in bron- 
cho-pneumonia. The vitality of infants and young children is so easily 
lessened by a disease so severe as broncho-pneumonia that the respimtory 
power is likewise quickly diminished, and we should avoid, except where 
they are especially needed, such drugs as opium. Ipecac in minute doses 
seems to facilitate the removal of the mucus. During severe paroxysms 
an atmosphere of steam or the administration of oxygen is indicated, accord- 
ing as the symptoms seem to be produced by a tenacious exudate or by 
unaerated lung-tissue. In cases where cyanosis and dyspnoea are urgent, if 
these depend upon mechanical obstruction with its resulting atelectasis, an 
emetic is occasionally demanded. In some cases, also, where much exhaus- 
tion arises from incessant coughing, small doses of tinctura opii camphorata 
may be used w^ith caution, and discontinued as soon as possible. AMien the 
urgent symptoms are caused by the heightened temperature, much relief 



974 



PEDIATRICS. 



can be obtained by reducing the temperature by means of the warm bath 
given at a temperature of 32.2° C. (90° F.). This may be followed by the 
warm wet pack, which can often be continued with benefit for several hours, 
and is especially beneficial in producing deep inspirations and thus aerating 
dependent portions of the lung. The position of the child should be changed 
from time to time, as there is a tendency for the inflammatory exudate to 
collect in the lower and back portions of the lungs. The administration of 
food at regular intervals is very important, and should be carried out rigor- 
ously. In most cases the chief part of the diet, if possible, should be milk. 
Although vomiting may occur in certain cases, as a rule, if the diet is care- 
fully regulated and the milk given once in two hours with stimulants 
adapted to the condition of the especial case, an over-sensitive condition of 
the stomach is seldom a serious obstacle to the treatment. In a number of 
cases the paroxysmal attacks of cyanosis and dyspnoea may be caused by a 
weak heart. In these cases the administration of brandy and digitalis, the 
latter in the form either of tincture or of infusion, for a few days, until the 
cardiac condition has improved, is indicated. Strychnine and nitroglycerin 
may also be used, and the former is considered especially important. 

When convalescence has been established the children are ofteu left in 
a very weak condition, and careful attention should then be paid to the 
nursing and to the general hygiene. The strength should be restored by 
means of tonics, and, if possible, the child should be removed to an equable, 
warm climate. 

Case 461. 




Acute broncho-pneumonia. Female, 4>^ years oM, The black circles indicate areas of 
consolidated lung-tissue ; the black spots indicate rales. 



Here is a little girl (Case 461), four and a half years old, in whom the physical exami- 
nation shows very marked lesions of broncho-pneumonia. 

There is no tubercular history in her family. She had scarlet fever when she was one 
year old, measles when she was one and a half, pertussis and varicella when she was three, 
and bronchitis when she was three and a half years old. JShe had otherwise always been 



DISEASES OF THE LUNGS. 



975 



well up to nine days ago, when she began to complain of headache and pain in her chest. 
At that time she vomited, and two days later began to cough and to be rather somnolent. 




Acute broncho-pneumonia. Recovery iu tliirty days. 

Her bowels were regular. On physical examination the child is found to be rhachitio, as 
shown by a rosary, enlarged epiphyses of the wrists and ankles, and marked bowing of the 
legs. On entering the hospital her pulse was 160, her respirations 60, and her temperature 



976 PEDIATRICS. 

39.4° C. (103° F.) in the morning and 40° C. (104° F.) in the evening. She seemed very 
sick, had considerable cough, but no expectoration ; there was some dyspnoea, and at times 
she was somewhat cyanotic. On examining the chest the percussion was found to be reso- 
nant, but throughout both lungs there were moist rales. Nothing abnormal was detected 
on examining the heart and abdomen. She was treated with milk and brandy. 

On the following day she was in about the same condition, and her pulse, respirations, 
and temperature were as on entering the hospital. In certain circumscribed areas in both 
backs slight dulness was detected on percussion, with moist rales around the edges of these 
areas. 

On the third day the pulse had fallen to 136, the respirations to 40, and the tempera- 
ture to 38.3° C. (101° F.). 

To-day, the ninth day of the disease, the pulse is stronger and the child's condition is 
very much improved. The dyspnoea has disappeared almost entirely, there is no cyanosis, 
and she is more comfortable. On examining the front of the chest you notice that the 
resonance on percussion is normal, and I find no abnormal sounds on auscultation. On 
examining the back you will find certain circumscribed areas of dulness, the borders of 
which I have marked in black. One of these areas is between the edge of the scapula 
and the vertebral column, another is at the right base in the posterior axillary region, and 
another is at the left base just below the angle of the scapula. Over these areas of dulness 
bronchial respiration is heard. Just outside of the areas of dulness can be heard in limited 
areas moist rales of various sizes, which I have indicated by black dots. You will notice 
that the physical signs in this case of broncho-pneumonia correspond to the areas where the 
lesions of this disease are usually detected on physical examination. 

(Subsequent history.) Five days later the child was found to have much improved. 
During the following ten days the abnormal signs in the chest disappeared, but the pulse, 
respirations, and temperature did not become permanently normal for a week later. The 
child, after remaining weak and debilitated for some weeks, was finally discharged from the 
hospital in good condition. The chart of this case is seen on page 975. 

This case apparently arose in the course of a slight bronchitis occurring 
in a rhachitic child. I have told you that the prognosis of broncho-pneu- 
monia in rhachitis is usually unfavorable, but in this case the child possessed 
sufficient vitality not to succumb to the disease. 

In connection with this case, and with what I have just said of the 
gravity of the prognosis of broncho-pneumonia when occurring in connec- 
tion with rhachitis, I shall recall to your minds the case which I lately 
showed you in the wards of the City Hospital. 

The child (Case 462) was two years and one month old. Its mother died of pulmonary 
tuberculosis. It had bronchitis when it was one year old, and the cough continued for 
three months. One week before entering the hospital it was attacked with a severe cough, 
and began to lose in weight and to have diarrhoea. A physical examination showed that it 
was a case of marked rhachitis. The breathing was rapid and labored, there was consider- 
able cyanosis, and the child was dull and somnolent. Patches of dulness were found in 
various parts of the lungs, with moist rales of different sizes. The pulse varied from 140 
to 150, the respirations from 80 to 90, and the temperature from 38.8° to 40° C. (102° to 
104° F.). The symptoms increased in severity, the child grew weaker, and on the second 
day after it entered tbe hospital it died suddenly. 

When broncho-pneumonia attacks a child with such marked rhachitis as 
was shown in this case, a fatal issue almost always results. 

Here is a chart (Chart 34, page 977) showing the temperature and pulse 



DISEASES OF THE LUNGS. 



977 



of an infant (Case 463) eight months old, from the nineteenth day of an 
attack of broncho-pneumonia until convalescence was established. 



CHART 34. 





Days of Disease. 




w. 


19 


20 


Sl 


22 


23 


24 


25 


26 


27 


28 


29 


30 


31 


32 


33 


34 


35 


36 


37 


38 


39 


c. 


107° 
106° 
105° 
104 
103° 
102° 
101 
100° 

TEMP. 

98° 
97° 
96° 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


41.6° 

41.1° 

40.5° 

40.0° 

39.4° 

38.8° 

38.3° 

37.7° 

37.2° 
37.0° 
36.6 

36.1° 
35.5° 

35 0° 














































































































































> 


































/ 


A 




/ 


/ 


/ 




























h 


/ 


/ 


/ 


/ 


/ 


/ 


/ 


/ 




A 


/ 


/ 


^ 














/ 


h 


/ 














/ 


l^ 


/ 


/ 


/ 




V 












/ 


/ 


/ 


























\ 


\ 


/ 








































\ 


/ 












































^ 


^ 


































































































































150 
140 
130 
120 
110 
100 


/ 




\y 


/I 


l^ 








/ 










A 


\ 














J 
^ 














^ 


■ 1 


V 


/ 


k 






/ 


n 






































/ 






[^ 












































\ 































































































Acute broncho-pneumonia. Infant, 8 months old. Recovery in thirty-six days. 



The infant, a male, had always been strong and well. The parents were healthy, but 
on the father's side a number of brothers and sisters had died of pulmonary tuberculosis. 
It was being nursed by its mother, who was strong and well. On December 16 the infant 
did not seem well, and on the following day, after having passed a restless night, bronchial 
respiration and rales were detected at the base of the right lung. The temperature on that 
day varied from 38.3° C. (101° F.) in the morning to 39.4° C. (103° F.) in the evening. 
There were no symptoms except a slight cough, and the respirations were accompanied by 
an expiratory moan. Until December 23 it took about a quart of milk in the twentv-four 
hours, but on the 24th it refused to take any food, and the temperature, which had been 
gradually coming down so as to reach almost 38.3° C. (101° F.) in the evening, began to 
rise, and dulness and fine rales were detected in the left lower back. The pulse at this 
time rose to 160, but was regular and strong ; the respirations varied from 60 to 70. The 
alse nasi showed more active dilatation, and there was slight twitching of the arms and 
lands. The cough became more frequent, and there was slight diarrhoea. These symp- 
toms continued for several weeks, when they lessened in severity and the temperature fell 
to the normal. 

The case was treated with brandy and digitalis, and finally recovered entirely. 

When this child was eight years old he was attacked with purpura rhoumatica, 
followed in a month by nephritis, and one month later by a severe attack of broncho- 
pneumonia, which involved extensive areas in both lungs and was accompanied by constant 

62 



978 



PEDIATRICS. 



diarrhoea, delirium, cyanosis, and dyspnoea, resulting in death from exhaustion iu the 
second week of the disease. 

This next case, a girl, two years old (Case 464), had up to the present attack been strong 

















CHAKT 


35. 


















Days of Disease. 




F. 










1 


2 


3 


4 


5 


6 


7 


8 


9 


10 


11 


12 


c. 


107° 
106° 
105 
104 
103° 
102° 
101° 
100 
99 

NORMAL 
TEMP. 

98° 
97° 

96; 

95° 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


41.6° 

41.1° 

40.5° 

40.0° 

39.4° 

38.8° 

38.3° 

37.7° 

37.2° 
37.0° 
36.6° 

36.1° 

35.5° 
35.0° 
















































/ 


'rom 


ho-l 


neumonh 


t 










2 










J 






\ 














^ 


















\ 














^ 






^ 




/ 






\ 
























/ 


/ 


/ 




\ 


1 


/ 










\ 








/ 


/ 


/ 






\ 


/ 












\ 


















/ 


/ 


/ 












^^ 
















/ 




/ 


/ 






























/ 


/ 


y 




























/ 








































































150 
140 
130 
120 
110 


















~h 
















^ 
^ 


















/ 


































1 




/ 


/ 














/ 


^ 










1 




/ 










^ 




^ 






^ 












/ 




A 
















N 












/ 






y\ 




90 
80 
70 
60 
























I 










































































-/ 
































50 
45 
40 
35 
30 
25 
20 
15 
10 


/- 


\ 






























-to 




\ 














1 






















/ 




/ 


























\ 




/ 


/ 






1 




































/ 


































y 




































^ 











































































































Broncho-pneumonia following crisis of measles. Child, 2 years old. 



and well. There is no tuberculous history in the family. She entered the hospital six days 
ago, and was placed in the isolating ward, as she was found to have measles. On entrance 



DISEASES OF THE LUNGS. 979 

her temperature was 89.8° C. (103.7° F.), the pulse was 120, and the respirations were 62. 
An examination of the chest showed the heart to he normal. The percussion showed 
normal resonance and harsh puerile respiration, with numerous line and coarse moist rales 
throughout both lungs. Nothing else abnormal was detected. 

Five days ago the temperature fell to 38.1° C. (100.7° P.), four days ago to 37.3° 0. 
(99.2° r.), and day before yesterday was just above normal. During these days the efflo- 
rescence rapidly faded, and she seemed better, though she occasionally had a harsh cough. 
Yesterday she had a slight rise of temperature, but there were no marked symptoms until 
to-day, when the temperature rose to 40° C. (104° F.), the pulse to 160, and the respira- 
tions to 50. She is, as you see, very restless, and has considerable dyspncea. She is pallid 
and sometimes slightly cyanotic. On physical examination there is found diminished reso- 
nance over an area in the lower part of the left back. Over this area the breathing is bron- 
chial, and there is also a number of moist rales. On the right side of the thorax, especially 
at the base of the lung, there are numerous coarse moist rales and harsh respiration, but 
no dulness. 

This case illustrates the rapid development of a broncho-pneumonia during an attack 
of measles, occurring after the temperature produced by the measles had fallen to the nor- 
mal and while the efflorescence was disappearing. The physical signs show the presence 
of small areas of consolidation in the left lung, and the usual diffuse bronchitis throughout 
the right lung and parts of the left lung. 

(Subsequent history.) This chart (Chart 35) shows the course of the temperature, 
pulse, and respiration during the next twelve days. The pulse continued to be rapid and 
the respirations to be somewhat raised for some days after the temperature became normal. 
The abnormal signs in the chest disappeared, and the child made a rapid recovery. 

Chronic Broncho-Pneumonia. — I have already described the patho- 
logical lesions which occur in chronic broncho-pneumonia. In a certain 
number of cases, after a child has had an attack of acute broncho-pneumonia 
the physical signs of consolidation may persist, although apparent recovery 
has occurred so far as the general symptoms are concerned. When this 
occurs the fever may return after a variable period, and the child, after 
having become still more emaciated, may die after a number of months of 
exhaustion. Instead of this fatal issue, the child, as has been shown by 
Delafield, may be left with a chronic form of the disease, which may last 
for many years and be accompanied by symptoms of cough, dyspnoea, and 
at times periods of fever. The most common termination of these cases is 
in acute general miliary tuberculosis. In certain cases, however, where 
only a small portion of the lung has been affected, the child may recover 
as it grows older. Broncho-pneumonia of a subacute or a chronic type is so 
apt to develop in the lungs of young children during the course of any 
disease of a prolonged nature, that frequent examinations of the lungs 
should be made, in order that the insidious development of these pulmonary 
lesions may not be overlooked. 

The treatment of these chronic cases of broncho-pneumonia is essentially 
climatic. The child should be taken to a warm dry climate of high alti- 
tude, where it can live in the open air, and where it will not be subjected to 
frequent atmospheric changes. 

Atelectasis. — Atelectasis is a collapsed and unaerated condition of the 
air-vesicles. It may be congenital or acquired. 

Congenital atelectasis arises because the infant has not sufficient general 



980 PEDIATRICS. 

vitality and respiratory power at birth to inflate fully all parts of its lungs. 
There may be an obstruction by mucus. There are in these cases areas 
of uninflated pulmonary vesicles of varying extent. These vesicles at the 
post-mortem examination can easily be artificially distended, and then can- 
not be distinguished from those which have been normally inflated. 

The symptoms of congenital atelectasis are cyanosis, dyspnoea, rapid 
respiration, rapid, feeble, and often intermittent pulse, a temperature usually 
lowered, and dulness on percussion with lessened respiration over the atelec- 
tatic area. These are the typical physical signs of atelectasis, but in many 
cases some or all of these signs are absent and the areas of atelectasis are 
detected only at the post-mortem examination. 

The prognosis in these cases varies according to the extent of the pul- 
monary tissue involved and the vitality of the infant. As a rule, the 
prognosis is very unfavorable. 

The treatment of atelectasis is to stimulate the infant, and to endeavor 
to raise its temperature by means of a warm pack. In a number of cases I 
have found the administration of small quantities of oxygen to be of bene- 
fit. Artificial inflation of the air- vesicles has not proved to be an especially 
valuable form of treatment. 

Acquired atelectasis is a symptom of some other disease, and I have 
already spoken of it sufficiently in connection with what I have said con- 
cerning broncho-pneumonia. Acquired atelectasis undetected during life is 
frequently found at the post-mortem examination of infants and young 
children dying of almost any disease. 

Lobar Pneumonia. — Lobar pneumonia is an acute self-limited disease 
of the lung, running a definite course and caused by the diplococcus 
pneumoniae. 

Fig. 140. 





# 

(^ 

f^ ® ® 

^ % 


% 


^ # 


(3© 


® % 


Diplococcus pneumonifp,. 



Etiology. — Although lobar pneumonia may occur at any age, it is not 
met with so commonly in infancy and in early life as broncho-pneumonia. 
Exposure to cold, and especially to sudden atmospheric changes, apparently 
renders the individual more susceptible to the invasion of the micro- 
organism which causes this disease. Here is a specimen (Fig. 140) of this 
organism, taken from the sputum of a case of lobar pneumonia. It shows 
the morphology. 



DISEASES OF THE LUNGS. 981 

According to Delafield and Prudden, these germs during their develop- 
ment are distinctly spheroidal, but in their mature condition they often 
become slightly elongated and a little broader at one end than at the 
other, which gives them a lanceolate form. They are very apt to occur in 
pairs, and are frequently seen in short chains, but rarely in long chains. 
Very frequently when growing in the living animal the pneumococcus is 
surrounded by a distinct homogeneous capsule of varying thickness. The 
coccus itself is readily stained ; the capsule is stained with difficulty. 

Pathology. — The pathological condition which occurs in acute lobar 
pneumonia is an acute exudative inflammation which involves progressively 
the w^hole of one lobe, or the larger part of one Kmg, or portions of both lungs. 
There is no especial distinction between the lesions of lobar pneumonia as 
they occur in children and those which are met with in adults, except so far 
as the anatomical conditions differ according to the age of the individual. 
The stages of congestion, red hepatization, gray hepatization, and resolution 
take place in succession in the pneumonia of the child as in that of the adult. 
In the stage of congestion the lung is hypersemic and oedematous and the air- 
vesicles contain fibrin, pus, granular matter, red blood-cells, and epithelial 
cells. The epithelium of the air- vesicles is swollen, and there are large num- 
bers of white blood-cells in the capillaries. The large bronchi are congested. 
The small bronchi contain the same inflammatory products as do the air- vesi- 
cles. This stage lasts only a few hours, as a rule, but may be protracted for 
several days. When the exudation of the inflammatory products has reached 
its full development the presence of these products within the air- vesicles and 
bronchi causes the lung to be slightly enlarged, and at this time it is said to 
be in the condition of red hepatization. After the air-vesicles have become 
completely filled with exudation there follows a period during which the 
exudation first becomes decolorized and then degenerated. This is the 
period of gray hepatization. This happens at a variable time, w^hich is 
usuallv shorter in children than in adults. The color finally becomes 2:ray. 
The exudate then undergoes still further degeneration and softening, and is 
removed by the lymphatics. This is the stage of resolution. Resolution 
should begin immediately after defervescence and be completed within a few 
days, but it may not begin until a number of days after defervescence, and 
may be unusually protracted. 

The bronchi are almost always affected in lobar pneumonia. The pneu- 
monic process may occur in small patches, but usually involves an entire 
lobe. The lower lobes are the ones which are most frequently affected in 
early life, but the locality of the pneumonia is of pathological rather than 
of clinical importance, as the disease may attack any part of the lungs. It 
is generally a unilateral disease, but in some cases it may be bilateral. 

Symptoms. — The onset of acute lobar pneumonia is, as a rule, sudden, 
and in the infant or young child is frequently accompanied by vomiting and 
sometimes by convulsions ; the latter, however, is uncommon as an initial 
symptom after the period of infancy. An initial rigor is uncommon. Pain 



982 PEDIATRICS. 

is probably present, but cannot usually be located by the child with the 
same precision as by the adult, young children often referring the pain to 
the abdomen. Cough is a common symptom, not only in the beginning 
of the disease but also during its whole course, and often seems to be 
painful. It may, however, be absent for several days in the beginning of 
the attack. There is rarely any expectoration before the seventh or eighth 
year. In some cases during the height of the disease there is delirium. In 
the milder cases the delirium may be merely a slight wandering, but in the 
more severe cases the children may become much excited, and the delirium 
may be accompanied by contracted or dilated pupils, and even involuntary 
passages of urine and of fseces, with continual movement of the head, mus- 
cular twitchings, and other symptoms which may simulate closely those of 
cerebro-spinal meningitis. In place of the delirium and the excited condi- 
tion there may be a condition of stupor which sometimes simulates the 
stupor of tubercular meningitis. In another set of cases the nervous symp- 
toms markedly simulate those of the non-tubercular form of meningitis. 
Meningitis in any form, however, rarely occurs in the course of pneumonia. 
Violence of the symptoms is not common. Marked cerebral symptoms 
seem to depend more on the height of the temperature and the extent of 
the lung involved than on any especial part of the lung being affected, such 
as the apices. In infancy and in the early years of childhood, in place of 
these cerebral symptoms there may be simply an apathetic condition during 
the height of the disease, and the infant, although somewhat somnolent 
and restless, often shows no other nervous excitement. The course of the 
disease is usually shorter in young than in older children. 

The rate of both the pulse and the respiration is increased, but the 
greatest increase is shown in the rate of the respiration. This is much 
higher proportionately to that of the pulse than is usually the case in other 
affections which would be likely to simulate lobar pneumonia. There is 
commonly dilatation of the alse nasi, and it is seldom that this symptom is 
absent in pneumonia. The pulse varies from many causes, among which is 
the nervous condition of the especial child. It may be 120 to 150. 

The temperature is a very important symptom in acute lobar pneumonia, 
and is almost diagnostic of the disease. In the initial stage it rises at once 
to 39.4° or 40° C. (103° or 104° F.) ; it remains high, with slight remis- 
sions of about two degrees in the morning, for a number of days, and then 
in a large number of cases falls to the normal within twenty-four hours by 
crisis. The time when the temperature falls and the crisis takes place varies. 
It may occur as early as the third or fourth day, but is usually between the 
fifth and the eighth day. It may, however, be delayed until the ninth or 
tenth day, and in rare cases still longer. When the temperature falls at the 
crisis of the disease it is very apt to be subnormal, and to remain so for a 
number of days. Sometimes after the temperature has fallen to the normal 
it may rise again, but, as a rule, another rise of temperature points towards 
the involvement of some fresh area of the lung or to some complication. 



DISEASES OF THE LUNGS. 983 

such as pleurisy. The fall of temperature at the time of the crisis is often 
accompanied by symptoms of great prostration and even collapse, and it 
is therefore important in young children to watch carefully for the crisis 
and to be prepared to combat these symptoms. The normal height of the 
temperature in acute lobar pneumonia, according to the extensive observa- 
tions of Holt, is from 40° to 40.5° C. (104° to 105° F.). In children 
over three years of age the temperature curve resembles the adult type in 
being regular and falling by crisis, while under three years of age the pro- 
portion of typical cases is much less, and there is more irregularity in the 
course of the temperature, which may fall by lysis. The younger the indi- 
vidual the more likelihood there is to be a wide fluctuation in the range 
of the temperature, which has a tendency to be of the remittent type even 
in uncomplicated cases. 

The physical signs of lobar pneumonia are the same as occur in adults. 
There is dulness on percussion over the affected area of the lung where con- 
solidation has taken place, with bronchial respiration, increased vocal fremi- 
tus, and increased vocal resonance. In the initial stage of the disease fine 
rales are heard at times, but not so commonly in children as in adults. When 
resolution is taking place, moist rales of all sizes are heard. These are the 
typical signs of lobar pneumonia. In some cases the physical signs are 
entirely absent for a number of days, and the diagnosis has to rest upon the 
heightened temperature, the increased respirations and pulse, and the dila- 
tation of the alse nasi. In the early days of the disease the cough may be 
absent ; this renders the diagnosis still more difficult. The cough may con- 
tinue and the physical signs remain unchanged for a number of days after 
the temperature has fallen. The physical signs in some cases immediately 
disappear when the temperature becomes normal. Fine dry rales are not 
heard so frequently in the lobar pneumonia of young children as in that of 
adults. 

In certain cases, where hepatization of the lung has taken place in the 
usual way and the crisis has come with a fall of temperature, resolution will 
fail to take place and the lung will remain solidified sometimes for a long 
period. Although an infection by the bacillus tuberculosis may be sus- 
pected in many of these cases, from their protracted course and from the 
prostration which usually accompanies them, yet such infection does not 
necessarily take place, and resolution often finally occurs. In these cases the 
lung is left apparently in the same normal condition as if tliis variation in 
the resolution had not taken place. 

As an illustration of delayed resolution in lobar pneumonia I shall report to you the 
case of a little girl (Case 465), four years old, who, when she was perfectly well and strong, 
was suddenly attacked with vomiting, pain in the right side, and cough accompanied, ac- 
cording to her mother, by a reddish-brown sputum. Physical examination on the follow- 
ing day revealed nothing abnormal except a few line moist rales at the base of the right lung 
behind. The pulse was 170, the respirations 60, and the temperature 39.4° C. (103° F.). On 
the following day the temperature still remained raised, and there was dulness on percussion 
over the lower right lobe behind, with bronchial respiration. On the following day the dul- 



984 PEDIATRICS. 

ness had extended over the whole of the right lung in frant and behind. The temperature 
varied from 38.8° to 39.4° C. (102° to 103° F.), the pulse from 150 to 160, and the respira- 
tions from 50 to 60. These symptoms continued until the eighth day from the onset of the 
attack, when the temperature was found to be 38.4° C. (101.2° F.), the respirations 48, 
and the pulse 160. During the next nine days the temperature, pulse, and respirations 
remained the same, and there was no change in the physical signs of the lung, except 
that in addition to the dulness and bronchial respiration a number of fine moist rales were 
heard in the back and in the axillary regions. The child was seen at this time by me in 
consultation with Dr. Calvin Ellis, and the physical signs were verified. During the 
next week no change took place in the temperature, pulse, respiration, or physical signs. 
Some days later the temperature fell to the normal, the respirations to 36, the pulse to 135, 
the dulness began to disappear, and the numerous coarse and fine moist rales of resolution 
appeared. Eesolution took place rapidly, and a week later, thirty days from the onset of the 
attack, the lung appeared to be in a perfectly normal condition. From that time the child 
gained rapidly in strength and weight and recovered completely. 

In some cases the child may show the rational signs of pneumonia, quick 
respirations, rapid pulse, dilatation of the alse nasi, apathy, delirium, and 
perhaps vomiting and convulsions, for many days before the physical signs 
appear in the lung. In order to illustrate this delay in the appearance of 
the physical signs of lobar pneumonia I shall report to you briefly two cases 
which I saw in consultation with Dr. Chase, of Dedham. The whole 
course of the disease and the physical signs were so similar in both instances 
that one description will suffice for both. 

They were two boys (Cases 466 and 467), brothers, the older boy being three years old 
and the younger sixteen months old. The older boy was attacked on November 19, and 
the younger one on November 20, with continuous vomiting, which lasted without much 
intermission until November 26. In addition to the vomiting the temperature rose in the 
first twenty-four hours to 40.5° C. (105° F.), and until November 26 varied from 40° to 
40.5° C. (104° to 105° F.). The respirations varied from 40 to 50, and the pulse from 150 
to 160. Both children soon became unconscious, were very restless, rolled their heads con- 
tinuously, and had contracted pupils. On November 26 the temperature fell to 39.4° C. 
(103° F.), and during the next two days varied from 39.4° to 40° C. (103° to 104° F.). 
On November 27 a small area of absolute dulness with bronchial respiration was detected 
in the older boy over the left upper lobe in front, and on the following day in the younger 
boy over the left lower lobe behind. After the first few days there was slight cough in 
both cases, with movement of the alse nasi. On November 30 the temperature in both 
children rose to 40.5° C. (105° F.), and until December 2 it varied from 40° to 40.5° C. (104° 
to 105° F.). On the evening of December 2 the temperature in the older boy suddenly 
fell from 40.5° C. (105° F.) to 35.5° C. (96° F.). The child became cold, the pulse became 
feeble, and the respiration could scarcely be detected. The application of the hot pack and 
an enema of hot brandy-and-water rapidly revived the child. The same fall of tempera- 
ture occurred in the other boy on the following morning. In both children signs of resolu- 
tion were detected before the temperature fell, the lungs in both cases rapidly became nor- 
mal, and after a short convalescence the children recovered completely. 

In some cases lobar pneumonia may attack both lungs. Again, after the 
disease has run its course and the temperature has fallen to the normal, a 
fresh portion of the lung may be attacked and the temperature may rise 
again. In rare instances in otherwise typical cases of lobar pneumonia I 
have been unable to detect any rales over the area of solidification through- 
out the whole course of the disease. 



DISEASES OF THE LUNGS. 985 

Diagnosis. — The diagnosis of lobar pneumonia, when the typical tem- 
perature and the characteristic physical signs are present, is not difficult, but 
there are a number of atypical cases in which a doubt might easily arise for 
a number of days after the invasion of the disease. An early diagnosis 
from a pleuritic effusion and from other pulmonary affections is at times 
impossible. 

The differential diagnosis between lobar pneumonia and a pleuritic effu- 
sion may be quite difficult in the early stages before the characteristic areas 
of dulness have been established. In both diseases dulness over a limited 
area, and bronchial respiration without any especial difference in the vocal 
fremitus and vocal resonance, and without evidence of a friction-rub or of 
rales, may make the two diseases simulate each other closely and compel 
us to wait for further developments before determining which disease is 
present. 

From tubercular disease of the lung the differential diagnosis is usually 
not difficult, except in young infants, in whom the tubercular process with 
its corresponding symptoms may in rare cases simulate lobar pneumonia. 

The disease from which a differential diagnosis should especially be made 
is broncho-pneumonia. Lobar pneumonia and broncho-pneumonia are so 
distinct, however, in their previous history, initial stage, course, and dura- 
tion that, if care be taken to note closely all these stages of the two diseases 
and to arrive at a diagnosis from the evidence given by all the stages and 
not by any one stage, the diagnosis can, except in the very early days of the 
disease, usually be determined. Lobar pneumonia, in contradistinction from 
broncho-pneumonia, is a primary disease, characterized by a sudden onset 
and a regular temperature, the rise being sudden. This is accompanied by 
a corresponding rapidity of the pulse and respirations, dulness on percus- 
sion usually involving and limited to one lobe or one lung, with increased 
vocal fremitus and resonance, and bronchial respiration over the dull area. 
This is followed by a fall of temperature and by a rapid resolution. The 
duration is short and definite. Broncho-pneumonia, on the other hand, is 
usually secondary to a preceding bronchitis, occurring either alone or in the 
course of some other disease. It is characterized by a slow and insidious 
onset, except when occurring in the course of measles ; it has an irregular 
temperature, the rise usually not being so sudden or so high as in lobar 
pneumonia, and the respirations and pulse slowly rising with the tempera- 
ture. There is often an absence of change in percussion, the dulness if 
present showing itself in small patches and commonly in both lungs. There 
is also often an absence of marked vocal fremitus or vocal resonance, and 
of bronchial respiration, except where the patches of dulness are pronounced. 
Moist rales of all sizes may be heard in circumscribed areas throughout both 
lungs. The temperature is usually of a remittent type, and this condition 
lasts for weeks rather than days. The resolution is slow. The duration is 
often prolonged. If these pictures of the two diseases are borne in mind, 
an error in the differential diagnosis will seldom be made. In the doubt- 



986 PEDIATRICSS. 

ful cases, where the characteristic course of either disease is absent, it will 
usually be found that we are dealing with a case of broncho-pneumonia, 
which is an exceedingly variable disease, rather than with lobar pneumonia, 
in which some of the characteristic features of the disease are almost inva- 
riably present. 

In making the diagnosis between pneumonia and meningitis it is of 
much aid to remember that the slow intermittent pulse, slow irregular respi- 
ration, and moderate temperature of meningitis are uncommon in lobar 
pneumonia, where in most cases the pulse is quick and regular, the respira- 
tions rapid, and the temperature high. It is not uncommon, however, to 
find irregularities and intermissions in the rapid pulse of pneumonia. The 
younger the individual, as I have already stated in my lecture on menin- 
gitis (page 612), the more likely are the symptoms of tubercular menin- 
gitis to be replaced by those of the non-tubercular form of the disease, which 
may often simulate closely the symptoms of pneumonia. The convulsions 
which occur in pneumonia do not differ from those which occur in menin- 
gitis or, in fact, in any other acute disease. A careful physical examina- 
tion should be made at every visit, once or twice a day if possible, as in 
this way the masked symptoms of a pneumonia may at times be detected 
where they would be overlooked if only an occasional examination were 
made. 

After the first four or five days, as a rule, the differential diagnosis be- 
tween cerebral disease and pneumonia is not difficult. 

Complications. — The complications of acute lobar pneumonia are 
not very numerous. At times a pericarditis may occur, with its resulting 
effusion, but these cases are rare. The most common complication is a 
pleuritic effusion, which, especially in young infants, is apt to be purulent. 
In many cases the onset of the disease and its initial symptoms are ap- 
parently characteristic of pneumonia, and yet a few days later it becomes 
evident that a purulent pleuritic effusion has either complicated the pneu- 
monia or was the original disease, simulating in its symptoms the early 
stage of lobar pneumonia. Isobar pneumonia is at times a serious com- 
plication of other diseases, and adds materially to their gravity. 

Gangrene. — One of the rare complications of lobar pneumonia is gan- 
grene of the lung. This lesion is never found as a primary disease, and is 
rare in children. It is usually met with in weak, debilitated children whose 
circulation is impaired. 

Prognosis. — The prognosis of lobar pneumonia is very favorable. In 
young infants, or in those who are weak and debilitated, it is often fatal, 
but in comparison with broncho-pneamonia tlie percentage of recovery is 
very high. When the temperature rises to 41.1° C. (106° F.) the prognosis 
is usually grave. The convulsions which occur in the initial stage of the 
disease in infants are commonly not of grave import. Occurring late in the 
disease they make the prognosis very unfavorable. When delirium occurs, 
although it may be severe, it does not render the prognosis especially un- 



DISEASES OF THE LUNGS. 987 

favorable. The fulminant type of the disease which sometimes occurs is a 
very fatal form. 

Treatment. — As lobar pneumonia is a self-limited disease of short 
duration, the children are not so apt to die of exhaustion, and as a rule 
only an expectant treatment is called for. Where the disease occurs in very 
young infants it is safer to administer stimulants from the beginning. In 
children, however, it is often not necessary to use any drug whatever, and 
it is safer to wait until there are indications that the disease will not run 
a benign course before using drugs. Such indications are especially given 
by the temperature. Although at times a high temperature does not neces- 
sarily indicate danger, since a temperature of from 40° to 40.5° C. (104° 
to 105° F.) is part of the regular course of the disease, yet if the tempera- 
ture rises above this point it is well to reduce it by means of bathing and to 
give stimulants in the form of brandy. The child should be placed in a 
room of an equable temperature of 20° or 21.1° C. (68° or 70° F.), and 
should be given milk every two hours. There is no necessity for making 
any external applications to the chest. The use of poultices is to be depre- 
cated, and in my experience is usually without benefit except in certain 
instances for the relief of pain. The nursing is of especial importance, 
and close watchfulness, especially at the time when the crisis is expected 
to take place. At this time the temperature in infants and young chil- 
dren may fall with such rapidity to several degrees below the normal 
point that collapse often takes place, the skin is cold and moist, and some- 
times the child becomes unconscious. Under these circumstances the pulse 
is feeble and intermittent, and in some cases death may occur unless active 
measures are taken for establishing reaction. The nurse should therefore 
be warned as the time for the expected crisis approaches to watch the 
child both night and day, and to have remedies ready to be used in case 
serious symptoms should arise. These remedies should be the external 
application of heat by means of the hot pack, and the administration of 
brandy by the mouth if the child can swallow, otherwise by rectal injection. 
I have known of a case (Case 468) where a child died in the collapse follow- 
ing the crisis of a lobar pneumonia. During the convalescence from pneu- 
monia the child should be protected from atmospheric changes, cold, and 
dampness for some time. 

Lobar pneumonia may occur in the earliest days of life. I have met 
with a case (Case 469) which on the third day of its life developed a lobar 
pneumonia and died in twenty-four hours. The autopsy was made by Dr. 
W. F. Whitney, and the characteristic hepatization was found. 

Here is a boy (Case 470), eight years old, who entered the hospital on the fourth day of 
an attack of lobar pneumonia. The attack began with vomiting and cough, but no pain, 
expectoration, or chill. An examination showed the right lung to be normal. On the left 
side of the chest an area corresponding to the lower lobe in the back was found to show 
absolute dulness on percussion, bronchial respiration, and many fine moist rales. Nothing 
else abnormal was detected. The child was very restless, but on the following day, the fifth 



988 



PEDIATRICS. 



from the onset of the disease, the temperature fell by crisis to the normal point. This chart 
(Chart 36) shows the typical temperature, pulse, and respiration of a case of lobar pneumonia. 







CHAKT 


36. 


(Case 470.) 






~ 


Days of Disease. 




in. 


4 


5 


6 


7 


8 


9 


10 


11 


12 


13 


c. 


107° 
106° 
105° 
104° 
103° 
102° 
101° 
100° 

o 

99 

NORMAL 
TEMPq 

98 
97° 
96° 
95° 


M E 


ME 


M E 


M E 


ME 


ME 


ME 


ME 


aiE 


M E 


41.6° 

41.1° 

40.5° 

40.0° 

39.4° 

38.8° 

38.3° 

37.7° 

37.2° 
37.0° 
36.6° 

36.1° 
35.5° 
35.0° 










































/ 


n 


















/ 




















































































V 




















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150 

140 

130 

120 

110 

100 

90 

80 

70 

60 






















1 
























s, 




















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50 
45 
40 
35 
30 
25 
20 
15 
10 






















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Lobar pneumonia, Male, 8 years old. Crisis on fifth day of disease. 

(Subsequent history.) After the crisis the child improved rapidly, and the physical signs 
disappeared in ten days. 



DISEASES OF THE LUNGS. 



989 



This little girl (Case 471), two and a half years old, entered the hospital on the third 
day of an attack of lobar pneumonia. To-day is the tenth day from the onset of the dis- 
ease, and this chart (Chart 37) shows one of the variations in the crisis which is quite fre- 
quently met with in young children, 

CHART 37. 





Days of Disease. 




F. 


3 


4 


5 


6 


7 


8 


9 


10 


c. 


107° 
106° 
105° 
104° 


ME 


ME 


ME 


ME 


ME 


ME 


M H 


M E 


41.6° 1 

41.1° 

40^^° 




































^ 




/ 










40.0° 

39.4° 

38.8° 

38.3° 

37.7° 

37.2° 
37.0° 
36.6° 

36.1° 

35.5° 

35.0° 


^ 
















102° 

101° 

100° 

99° 

NORMAL 

98 

97° 

96° 
1 95° 










^ 


/ 
















/ 
















/ 
















( 




















V 



































































Lobar pneumonia. Irregular crisis on eighth day. Female, 23^ years old. 

In this case the consolidated portion of the lung was the left lower lobe. The resolution 
was rapid and convalescence normal. 

This little girl (Case 472), eight years old, had pertussis when she was fourteen months 

Case 472, 




Lobar pneumonia. Female, 8 years old. The part of the luug involved by the pneumonic process 
is shown by black lines, and the area of diminished resonance and the fine r&les are marked by black 
spots. 



990 



PEDIATRICS. 



old, scarlet fever when she was five years old, and measles when she was six years old. 
rive days ago she lost her appetite, was very feverish, and was attacked with acute pain 









CHART 


38. 


(Case 4 


72.) 










Days of Disease. 




F. 


3 


4 


5 


6 


7 


8 


9 


10 


11 


12 


13 


14 


c. 

41.6° 

41.1° 

40.5° 

40.0° 

39.4° 

38.8° 

38.3° 

37 7° 

37.2° 
37.0° 
36.6° 

36.1° 
35.5° 
35.0° 


107° 
106° 
105° 
104° 
103° 
102° 
101° 
100° 
99° 

NORMAL 
TEMP 

98 
97° 
96° 
95° 


ME 


M E 


ME 


M E 


M E 


M E 


ME 


M E 


M E 


ME 


ME 


M E 










































































^ 




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/ 


j 
















































/ 


























\ 


r 




r^ 


v 


^ 






















M 




^-1 



































































































150 

140 

130 

120 

110 

100 

90 

80 

70 

60 
























































/ 
























/ 


^ 


1 
















/^ 


^ 


/ 




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\ 


^/ 




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50 
45 
40 
35 
30 
25 
20 
15 
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Lobar pneumonia. Female, 8 years old. Irregular crisis on sixth day. 

referred to the left side of the epigastrium and the lower part of the left axillary region. 
She has since had a hacking paroxysmal cough, with no expectoration. For the past few 
days she has been delirious. She vomited twice yesterday, and is very weak. Her tongue. 



DISEASES OF THE LUNGS. 



991 



as you see, is heavily coated, the alse nasi are working, her face is deeply flushed, and she 
has dyspnoea to such an extent that she has to be propped up on pillows. 

Her respirations are 45, difficult and painful, her pulse 120, and her temperature 39.5° 
C. (103.2° F.). A physical examination detects nothing abnormal in the front of the chest 
or in the right back. There is absolute dulness in the left back, beginning at the fifth rib 
and extending to the base of the lung and into the axillary region. Over this area of dul- 
ness there is increased vocal fremitus and bronchial respiration. In this area, also, there 
are a few moist rales Just above the upper border of the area of absolute dulness there 
are diminished resonance and a number of fine rales. This is the fifth day of the disease. 
Although the general condition of the child seems to show no especial change, yet the 
physical signs show that resolution has begun and that we may at any time expect the 
crisis to occur. 

(Subsequent history.) On the following day the temperature fell to 37.7° C. (100° F.) 
in the morning, but rose again in the evening to 39.1° C. (102.5° F.). On the following 
day, the seventh day from the beginning of the attack, the temperature fell to 37.2° 0. 
(99° F.), and then varied from 37.7° C. (100° F.) to 37.2° C. (99° F.) until the eleventh 
day, when it became normal. The chart (Chart 38) shows the pulse and respiration up to 
the fourteenth day from the beginning of the attack. 

This case is one which illustrates the fact that the physical signs of resolution may 
sometimes appear before the temperature falls and the crisis comes ; also that at the time 
of the crisis the temperature may fall, then rise again for twelve to twenty-four hours, and 
then fall to the nonnal, as in this case. The child recovered completely. 

This boy (Case 473), six years old, was taken sick four days before entering the 
hospital. 




Lobar pueumoniii. Three invasions. Male, li years old. 



On entering the hospital his pulse was 128, his respirations GO, and his temperature 
89.8° C. (103.8° F.). A physical examination showed that there was absolute dulness 
over the entire upper lobe of the right lung. Over this area of dulness there were bron- 
chial respiration and increased vocal resonance. There was also an occasional high-pitched 



992 



PEDIATRICS. 



rale. The left lung was normal. I have marked the lower border of the dulness produced 
by the consolidated upper lobe by a black line extending from the sternum just above the 











CHAKT 39. 


(Case 


473 


•) 










Days of Disease. 




F. 


5 


6 


7 


8 


9 


10 


11 


12 


13 


14 


15 


16 


17 


c. 


107° 
106° 

105" 
104° 

103° 
102 
101° 
100° 
99 

NORMAL 
TEMP 

98 

96° 
95° 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


41.6° 

41.1° 

40.5° 

40.0° 

39.4° 

38.8° 

38.3° 

37.7° 

37.2° 
37.0° 
36.6° 

36.1° 
35.5° 
35.0° 






















































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150 

140 

130 

120 

110 

100 

90 

80 

70 

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45 
40 
35 
30 
25 
20 
15 
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Lobar pneumonia. Male, 6 years old. 

right mamma and around into the axillary region. On the morning of the sixth day from 
the beginning of the attack the temperature fell to 37.7° C. (100° P.), but rose again in 
the evening to 40.5° C. (105° F.), and a physical examination then showed that the middle 



DISEASES OF THE LUXGS. 993 

lobe of the right lung was involved in front, as I have indicated by this second black 
line below the one which I have just described. The temperature during the next two 
days remained between 39.4° and 40° C. (103° to 104° T.), but on the following day, the 
ninth from the onset of the disease, the temperature suddenly fell to 37.6° C. (99.7° F.) 
in the evening, but rose the next morning to 39.3° C. (102.8° F.), and in the evening rose 
to 39.9° C. (103.8° ¥.). A physical examination then showed that the whole of the lower 
lobe was involved, as I have indicated by the third black line. On the following day the 
upper lobe began to show evidence of resolution, and the temperature fell to 38.3° C. 
(101° F.). Two days later the temperature began to fall by lysis, the physical signs of the 
upper and middle lobes entirely disappeared, and the temperature reached the normal point 
on the fourteenth day from the time of the onset. On the seventeenth day from the time 
of the onset the lower lobe was also found to be in a normal condition, and from that time 
convalescence was uninterrupted. 

Here is the chart (Chart 39), which shows the temperature, pulse, and respirations in 
this case from the fifth to the seventeenth day of the disease. 

In some rare cases tlie infection in lobar pneumonia is so intense that a 
rapidly fatal issue may occur. 

I have seen a little girl (Case 474), nineteen months old. who had been having so mild 
an attack of diarrhoea that she was playing about out of doors, suddenly attacked in the 
afternoon with convulsions and a temperature of 40.5° C. (105° F.). The convulsions con- 
tinued during the night, and she soon became comatose. On the following day the tem- 
perature still remained at 40.5° C. (105° F.), the respirations were much accelerated, and 
the pulse was about 120. An area of absolute dulness over the left lower lobe behind, with 
bronchial respiration and increased vocal resonance and fremitus, rapidly developed. The 
child did not respond to treatment, and died in the evening. 

TuBEECULOSis OF THE LuxG. — Tuberculosis of the lung is an affection 
in which certain lesions are produced in the lung by the bacillus tuberculosis. 
Although this tubercular affection may attack any organ or any part of the 
body, yet whenever it occurs elsewhere it is almost invariably found in the 
limg. It is well, therefore, to speak of this especial manifestation of tuber- 
culosis in connection with diseases of the lung. 

Etiology. — The cause of tuberculosis, as I have just stated, is an 
org-anism, the bacillus tuberculosis. Here is a specimen (Fig. 141, page 
994) which shows the morphology of this organism. 

These organisms are, according to Delaheld and* Prudden, slender, 
filamentous bacteria varying in length from one-quarter to one-half the 
diameter of a red blood-cell. They are frequently curved and bent, and 
may form short chains. This bacillus may retain its vitality for many 
weeks in a dried condition, but is killed by an exposure of fifteen minutes 
to a temperature of 100° C. (212° F.). In most cases it finds its way to 
the tissues by inspiration, although it may also gain access to the body by 
being swallowed. 

Pathology. — The pathological conditions which result from infection 
by the bacillus tuberculosis are very numerous. The lesions in the child 
do not differ from those which occur in later life, and I shall therefore not 
describe them in detail. 

The ordinarv chronic tubercular lesions met with in adults are seldom 



994 PEDIATRICS. 

seen in children, and it is rare for the tubercular process in children to 
begin at the apices of the lungs and gradually extend downward, as is com- 
mon in adults. When this occurs, it is usually in the later years of child- 
hood, when the conditions are beginning to approximate those of later life. 
The most frequent entrance of the tubercular affection to the lung is through 
the bronchial glands. This fact has been especially studied and described 



r 



Fig. 141. 






\ 

Tubercle-bacilli taken from the sputum in a case of tuberculosis of the lung. 

by Northrup. According to this investigator, in most cases the infection 
of tuberculosis in children is effected by the entrance of the tubercle-bacilli 
into the respiratory passages with the inspired air, and the lodging of them 
in the mucus of the air-passages or the alveoli of the lungs. They may then 
pass through at any point, and, being taken into the lymph-spaces, traverse 
the lymph-canals to the nearest glands and be retained there. These glands 
at the base of the lung receive and filter everything brought to them from 
the bronchial tract. The subsequent career of the bacilli depends upon the 
power of the tissues to withstand their further progress. They may die, 
or may remain inactive for a long period and later develop a tubercular 
process in the glands. These tubercular glands may finally break down 
and thus allow the bacilli to penetrate different portions of the lungs and 
produce their characteristic lesions. 

Tuberculosis of the lungs may occur in two forms : (1) acute tubercular 
broncho-pneumonia, and (2) chronic tuberculosis of the lungs. 

Acute Tubercular Broncho-Pneumonia. — According to Osier, acute 
tubercular broncho-pneumonia is common in children from the sixth month 
to the fifth year, a large proportion of the cases, however, occurring after 
the second year. It is common in children who have been debilitated by 
previous illnesses, and occurs especially after measles, pertussis, scarlet fever, 
and diphtheria, being most frequent in the first two. It may, however, de- 
velop in perfectly healthy, well-nourished children, and also, as Osier has 



DISEASES OF THE LUXGS. 995 

expressed it, may be a terminal process in cases in which local tubercular 
disease exists in other parts, such as the skin, bones, lymph-glands, or the 
uro-srenital tract. 

As in the other forms of broncho-pneumonia, the initial lesion is a bron- 
chitis and peribronchitis, the distinguishing tubercular features Ijeing casea- 
tion and necrosis of the consolidation with the presence of the tubercle- 
bacilli. The accompanying phenomena of atelectasis and emphysema occur 
as they do in non-tubercular broncho-pneumonia. In some cases the non- 
tubercular broncho-pneumonia precedes the tubercular disease, this occurring 
particularly after measles, scarlet fever, diphtheria, and pertussis. Accord- 
ing to Mosny, where the tubercular broncho-pneumonia follows the non- 
tubercular form, in addition to the lesions of the latter disease, there are 
found true tubercular processes, such as peribronchial nodules, tubercular 
infiltration, and caseous areas. Where the patient is the subject of a latent 
tuberculosis, such as may follow one of the infectious diseases, a non-tuber- 
cular broncho-pneiunonia may also develop. In these instances, according 
to Mosny, the lesions may be seen surrounding the tubercular peribronchitic 
nodides, or foci of non-tubercular or tubercular broncho-pneumonia are 
found scattered through the apices of the lung. 

Symptoms. — The symptoms of acute tubercular broncho pneumonia are 
very similar to those of non-tubercular broncho-pneumonia. According to 
Osier, in most cases the onset of the disease simulates that of the ordinary 
non-tubercular broncho-pneumonia so closely that a differential diagnosis 
between the two diseases cannot be made until after death, and even then 
the post-mortem appearances may not be those distinctive of tubercular dis- 
ease, and the pathological diagnosis can be determined only by finding the 
bacillus tuberculosis. The children may be attacked with cough, a height- 
ened temperature, and the physical signs of broncho-pneumonia. The 
physical signs, as would naturally be expected, are usually found in the back 
and lower portion of the lung rather than at the apices, as in adults, on 
account of the usual nidus of the tubercular lesions, — namely, the bronchial 
iymph-glands. In some cases the onset of the disease is not so acute, and 
its course not so rapid. The child emaciates and has only a moderate fever, 
but later the development of such symptoms as sweating, chills, and hectic, 
together with the signs of softening and breaking down of the lung-tissue, 
leads us to suspect that we are dealing with tuberculosis of the lung. 

Diagnosis. — The diagnosis, as a rule, is to be made bv takino- into con- 
sideration the family history of the child, as the tissues of children whose 
parents are tubercular show an especial liability to infection by the bacillus 
tuberculosis. The diagnosis can be made positively only in those cases 
where a specimen of the sputum can be obtained and examined for the 
bacillus tuberculosis. 

Prognosis. — The prognosis is invariably unfavorable. 

Treatment. — The treatment of tubercular broncho-pneumonia is the 
same as that of the non-tubercular Ibrm. 



996 PEDIATRICS. 

Chronic Tuberculosis of the Lungs. — Chronic tuberculosis of the 
lungs as it is ordinarily met with in adults is rarely seen in young children. 
During the first three months of life tubercular disease of any form is very 
rare, but in the latter part of the first year it becomes very common. The 
tubercular lesions which are found in the lungs in later life also occur in 
early life. Although cavities are not so commonly found in young children 
as in adults, it is not so much that they do not exist as that, their locality 
being more at the root and central portions of the lung, they are more diffi- 
cult to detect on physical examination. It has been noticed that large cavi- 
ties at the apex of the lung are rare in early life, but become more common 
as the child grows older. Tubercular disease of the lung is very irregular 
in the extension of its lesions in young children. Much more advanced 
lesions are usually found at the post-mortem examination than are detected 
during life. As I have already stated, the primary lesion of chronic tuber- 
culosis of the lungs is commonly a tubercular broncho-pneumonia. 

Symptoms. — The symptoms of chronic tuberculosis of the lungs differ 
but little in the child from those seen in the adult, and are marked by the 
same irregularities in their course. This is due to the varied forms of the 
lesions. In young infants the symptoms are so often obscure and the 
physical signs of the serious pathological conditions which exist in the lungs 
are so frequently masked that the diagnosis is apt to be very doubtful. 
There is often a history of tuberculosis in the parents. The more common 
symptoms of chronic tuberculosis of the lungs are gradual loss in weight, 
strength, and appetite, irregular and moderate fever, hectic, and sweating. 
The physical signs are slowly increasing dulness in certain areas of the 
lung, especially in the back, accompanied by rales and other evidences of 
solidification. Later in the disease the characteristic signs of cavities may 
develop. Cough is usually present, though it is sometimes so slight in the 
beginning as not to be especially noticed by the parents. Haemoptysis is 
rare in infants and in young children, but may be present in older children 
as they approach the age of puberty. As the disease progresses there is 
dyspnoea, usually of a moderate grade, with cyanosis, but in some cases con- 
siderable destruction may have taken place in the lung-tissue without the 
presence of any especial dyspnoea. 

The course of chronic tuberculosis of the lungs is rather more rapid in 
children than in adults, and it is seldom that the long-protracted course of 
the disease so frequent in adults is met with in children. Sometimes, how- 
ever, the child improves in its general health and may live for many years. 
In these cases the terminal phalanges of the fingers may become clubbed, 
and there is usually dyspnoea on exertion. 

Diagnosis. — The diagnosis is to be made from chronic empyema and 
from chronic non-tubercular broncho-pneumonia. The former disease can 
be readily eliminated by making an exploratory aspiration, but the latter 
can often be distinguished only by means of a bacteriological examination. 
In older children, where a specimen of the sputum can be obtained, the 



DISEASES OF THE LUNGS. 



997 



diagnosis is readily made bj the detection of the bacillus tuberculosis. In 
younger children, in whom expectoration does not take place, the diag- 
nosis is much more difficult, but if the children are carefully watched it is 
often possible to obtain a specimen of the sputum if the child happens to 
vomit, in which case particles of sputum may be coughed up with the 
vomitus and can be separated from it and examined. 

Prognosis. — The prognosis of chronic tuberculosis of the lungs where 
the symptoms are at all advanced is very unfavorable, but the post-mortem 
examinations of so many individuals who have died of non-tubercular dis- 
eases show the presence of old tubercular lesions which have apparently 
ceased to be of grave import, that we must acknowledge that it is possible 
for many cases to survive the invasion of the bacillus tuberculosis. 

Treatment. — The treatment of chronic tuberculosis of the lungs is 
essentially climatic, and the children should be removed at once, if possible, 
from a climate where the altitude is low and the atmosphere damp and sub- 
ject to great variations. Too high altitudes are also to be avoided. Where 
the child cannot be removed to a more favorable climate, strict attention 
to its general hygiene and to its food will in some cases be followed by an 
apparent arrest of the tubercular process. 

Case 475. 





Chronic tuberculosis of the lung. Female, 8 years old. 



This little girl (Case 475), eight years old, has a history of tuberculosis in her family. 
She had an attack of pertussis when she was six years old, and some months ago an attack 
of measles. Following the attack of measles she began to have headache, cough, and ex- 



998 



PEDIATRICS. 



pectoration. She complained of pain in her chest and abdomen, and of chilly sensations, 
and has progressively lost in weight and strength. A physical examination shows the 
skin to be dry and harsh and the heart normal. The left lung in front appears to be nor- 
mal. Behind over a small area at the upper part of the lung there are dulness, broncho- 
vesicular breathing, and some fine moist rales. 

Over the right upper lobe in front and behind there is dulness, and the expiration is 
prolonged and high-pitched. Over the dull region are heard medium and fine moist rales. 
I have indicated the borders of the areas of dulness by black lines, and the rales by black 
spots. I have also shown the area of cardiac dulness, the lower part of the sternum, and 
the lower border of the ribs, by dark lines, and the edge of the liver, which seems to be 
somewhat enlarged, by an interrupted line. 

This chart (Chart 40, Case 475) shows the irregular temperature which is commonly 
seen in cases of chronic tuberculosis of the lungs and is of a remittent type. 

CHAKT 40. 



Days of Disease. 


w. 












































c. 


107° 
106° 
105° 
104° 
103° 
102' 
101° 
100° 
99 

NORMAL 
TEMP. ^ 

98 
97° 

96° 
95 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


41.6° 

41.1° 

40.5° 

40.0° 

39.4° 

38.8° 

38.3° 

37.7° 

37.2° 
37.0° 
36.6° 

36.1° 

35.5° 
35.0° 


























































































































J 
































/ 


1 


J 






1 ' 


















1 






1 






/ 




/ 




r/ 


/ 


/ 




















/ 


/ 


/ 




/ 


/ 




/ 


/ 


/ 


/ 


/ 


/ 










/ 








/ 


/ 


/ 




/ 


/ 




/ 


/ 


/ 


/ 




/ 


/\ 




' 


^ 


/ 


/ 


/ 


1 


/ 


/ 


/ 




/ 






/ 


/ 


/ 






/ 




















1 


V 


j 






K 


L 




[.. 


— 

1 


..... 


























I 1 


































































































































t 



Chronic tuberculosis of the lung-. 

The expectoration has not yet been examined for the bacillus tuberculosis, but the diag- 
nosis is not doubtful, as the child is gradually failing and the signs of disorganization of the 
lung are slowly progressing. 



Pertussis (Whooping-Cough). — Pertussis is a highly infectious disease 
aifecting the respiratory tract and characterized by periods of spasmodic 
coughing, succeeded by a prolonged inspiration and accompanied by a 
peculiar sound called the " whoop." 

The cause of pertussis is probably a micro-organism, but this organism 
has not yet been determined. It is supposed that the contagium can be 
carried by a third individual, but usually it is directly communicated from 
one person to another. This contagium is probably contaiued in the expec- 
toration, and in this way houses where the disease is present may become a 
source of infection. The disease commonly occurs in epidemics duriug 
winter and spring. Sporadic cases occasionally appear, and in large cities 



DISEASES OF THE LUNGS. 999 

the disease is often endemic. Pertussis seems to have some especial rela- 
tion to measles, as children with the latter disease are liable to contract per- 
tussis, and in like manner those with pertussis are liable to contract measles. 
Pertussis may occur at any age, and the disease has even been known to be 
contracted in utero. One attack usually protects from a second. Debilitated 
children with catarrh of the respiratory tract are more subject than others to 
the contagium of pertussis. 

Pathology. — There are no pathological lesions distinctive of uncom- 
plicated pertussis. The condition which characterizes the paroxysmal at- 
tacks is extreme congestion of the different organs, such as the meninges, 
the lungs, the heart, and the kidneys. In grave or fatal cases the lesions 
are those which arise either from mechanical accidents, as emphysema or 
hemorrhage in various parts, as the eye or the meninges, or from such com- 
plicating diseases as broncho-pneumonia with its accompanying bronchitis 
and atelectasis. The bronchial glands are often found to be enlarged. 

Symptoms. — The period of incubation of pertussis is variable, but is 
usually less than two weeks. The symptoms in the beginning, and often 
for several weeks, are simply those of a bronchial catarrh with a slight rise 
of temperature and a cough which, though sometimes spasmodic, is often 
indistinguishable from that of an ordinary bronchitis. After a period vary- 
ing from a few days to tw^o or three weeks, the cough becomes more severe 
and of a more decidedly spasmodic character, and the peculiar whoop which 
characterizes the disease appears. The cause of these paroxysms seems to 
be a spasm of the larynx. This is accompanied by a feeling of suifocation. 
The paroxysm begins with a number of short, spasmodic, expiratory coughs, 
succeeded by a long-drawn inspiration and by the peculiar whoop. During 
the paroxysm, especially in severe cases, the face and mucous membranes 
become cyanotic, the eyes protrude, the conjunctivaj are congested, and the 
child looks as though it would die of asphyxia. After a few seconds the 
child, with a convulsive cough, expels some tenacious mucus, and is then 
relieved, or the attack returns again, and again subsides, and the symptoms 
of asphyxia pass away. These paroxysms are often followed by vomiting. 
They may occur only four or five times in the twenty-four hours, or again 
much oftener, — at times thirty, forty, or fifty times. At the onset of tlie 
attack the children are usually very much frightened, and either run to the 
mother or nurse for aid, or go to some part of the room where they can be 
undisturbed during the attack. In certain children, after the severe parox- 
ysms have lasted for some time, a small ulcer is formed on the fraenum of 
the tongue. This is because the frsenum is driven against the lower edge 
of the teeth during the paroxysms. During the course of the paroxysmal 
stage of pertussis it is quite common to have subconjunctival hemorrhages ; 
rarely deeper-seated hemorrhages take place in the meninges and in the 
deeper parts of the eye. In protracted cases petechia^ sometimes appear in 
the skin. Epistaxis may also occur. 

Examinations of the chest during the attack have shown that the pul- 



1000 PEDIATRICS. 

monary resonance is lessened during the expiratory stage and is clear during 
the prolonged inspiration. The auscultation usually shows diminution 
or absence of the respiratory murmur. Bronchial rales are heard occa- 
sionally. 

Koplik has noticed an increase in the area of the relative cardiac dul- 
ness during the paroxysmal stage of pertussis, which is often accompanied 
by a slight blowing murmur limited to the apex of the heart. This may 
well occur from the engorged condition of the right side of the heart, which 
subjects the heart to a great strain and may thus result in dilatation. The 
heart-sounds are apt to be irregular during the paroxysm, and in protracted 
cases during the intervals the pulse is often irregular and quickened, while 
the respirations are not especially increased unless some complication has 
arisen. In severe cases of pertussis the kidneys are sometimes congested, 
as shown by the appearance in the urine of albumin, casts, and blood-cells. 
Sugar has also been found quite frequently. 

After the disease has lasted for some weeks there is usually a certain 
amount of oedema of the face, especially under the eyes. The paroxysms 
are precipitated by nervous excitement or by an irritation in the throat or 
the respiratory tract, such as may result either from swallowing or from 
the inhalation of dust. The stage which is accompanied by the whoop and 
the more exaggerated paroxysms commonly lasts for three or four weeks, or 
even longer. The paroxysms then become less severe, and, although the 
cough continues, the whoop gradually becomes less frequent, and after three 
or four weeks more ceases entirely. When uncomplicated, the duration of 
the disease is usually three or four months. Slight changes in the atmos- 
phere or exposure will give rise to a relapse. The relapses, however, are 
not, as a rule, of a severe type, and in these cases the cough seems to arise 
from renewed irritation of the sensitive mucous membrane of the respira- 
tory tract rather than from a fresh infection by the specific germ. A per- 
sistent cough following an attack of pertussis may sometimes, according to 
Delafield, be caused by an insidious form of broncho-pneumonia. 

The period of infection is supposed to last for a certain time after the 
whoop has ceased, and if the cough continues it is well to allow for a period 
of infection of three weeks after this cessation. It is possible, however, that 
the whoop may occasionally occur for long periods after the child has ceased 
to be a source of infection to other individuals. 

Complications. — The complications which arise in pertussis arc usu- 
ally of a grave nature. The dangers from hemorrhages, unless in the 
form where they occur in the meninges, are not great. The complication of 
broncho-pneumonia is very serious, and often fatal. Severe and even fatal 
emphysema may occur in pertussis. 

Convulsions may arise not infrequently in infants and may end fatally, 
in these cases usually being caused by general reflex disturbance, by cere- 
bral congestion, or by some cerebral lesion. Spasm of the glottis may 
also very rarely cause death in greatly debilitated children. Excessive and 



DISEASES OF THE LUNGS. 1001 

obstinate vomiting at times becomes a serious complication, and may reduce 
the child's strength to a point which often gives rise to a doubt as to its 
recovery. It is an especially grave complication in infants who are already 
much debilitated. 

Diagnosis. — The diagnosis of pertussis cannot, as a rule, be made until 
the child whoops. Sometimes, however, where another child in the family 
has undoubted pertussis, a spasmodic cough may allow the diagnosis to be 
made before the whoop has developed. It is probable that a child may 
have pertussis without at any time developing the whoop. 

In some children a simple catarrhal laryngitis will simulate pertussis 
quite closely ; but, although in these cases there are paroxysms of spasmodic 
coughing, a pronounced " whoop'' does not occur, and the symptoms do not 
progressively increase and last for a long period. The diagnosis of pertussis 
can usually be made by the swollen aspect of the face, the paroxysmal cough 
followed by the expulsion of tough mucus and vomiting, and the long dura- 
tion of the attack. 

Prognosis. — Pertussis is a very serious affection in young infants, and 
also in older children who are debilitated or poorly cared for. Where it is 
complicated it is one of the most fatal diseases which occur in early life. 
When it occurs in older children the prognosis is favorable, provided that 
they have previously been well and strong, that they are well cared for, and 
that no complications arise. 

In some cases young infants, if their vitality is unusually good, and if 
they are carefully nursed and made to take a sufficient amount of food, 
show remarkable powers of resistance during attacks of pertussis. 

A case of this kind that came under my care was that of an infant (Case 476), five 
months old. In March she suifered from an attack of epidemic influenza, which lasted 
about twelve days, and from which she finally recovered. She was then attacked with 
measles, and after the temperature had fallen to the normal point she was attacked with 
pertussis. After two or three days the cough increased in severity, and after two weeks 
the infant began to whoop. The attack lasted for two months, and she* finally recovered. 
During the whole course of the disease she took over 600 c.c. (20 ounces) of modified 
milk in the twenty-four hours, and for a short time small doses of brandy were given. No 
drugs were administered. Here is a chart (Chart 41, page 1002) which shows the average 
range of temperature for two weeks when the disease was at its height. 

Treatment. — In the treatment of pertussis we must take into con- 
sideration the age of the individual, the stage of the disease, and the pres- 
ence or absence of complications. In the early months of life, after the 
disease has lasted for a week or ten days and has become more severe, 
the infant will usually show symptoms of general circulatory disturbance. 
The great strain thrown upon the heart during the paroxysms quickly 
affects the general strength of the infant, a marked interference with its 
nutrition soon appears, it loses in weight, and often it refuses its food. At 
times it will become somewhat cyanotic even between the paroxysms, and 
there is danger not only from the severity of the paroxysm, but also from 



1002 



PEDIATRICS. 



the vitality of the infant being so much interfered with as to prevent its 
recovery. In cases of this kind the nursing is of the utmost importance. 
The infant should never be left alone, should always be taken up whenever 
a paroxysm is approaching, and should be assisted in various ways until 
the paroxysm is over. Holding the infant in different positions, sometimes 
bending the head and body forward at the end of the paroxysm so as to aid 
by gravity the expulsion of the tenacious mucus, is desirable. At times, 
also, the finger covered with a thin cotton cloth can be quickly introduced 











CHART 


41. 


(Case 476.) 












Days of Disease 




in. 


14 


15 


16 


17 


18 


19 


20 


21 


22 


23 


24 


25 


26 


27 


C. 


107° 
106° 
105° 
104° 
103 
102° 
lOi 
100° 
99° 

NORMAL 
TEMP. 

98° 
97° 
96° 
95° 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


ME 


41.6° 

41.1° 

40.5° 

40.0° 

39.4° 

38.8° 

38.3° 

37.7° 

37.2° 
37.0° 
36.6° 

36.1° 

35.5° 
35.0° 










































































































































































X 




























^ 


l^ 


►^ 


^ 


^ 


^ 


M 




,^^ 


_^ 


,^ 


,^ 




















1 




























■ 































































































Pertussis. Female, 5 months old. 



into the throat and the mucus withdrawn in this way. It is of the utmost 
importance that the infant should be surrounded continually by fresh air. 
For this purpose two rooms should be used, if possible, one of which should 
have all the windows thrown wide open, so that the air can be completely 
changed before the infant is brought into it, and the patient should be alter- 
nately taken from one room to the other, the temperature of the rooms being 
kept as equable as possible. The nutrition of the infant is so easily af- 
fected that the utmost attention should be paid to the administration of the 
food. Small quantities of a milk carefully modified to suit its digestion 
should be given at frequent intervals, preferably after the occurrence of a 
paroxysm, as it is then more likely to retain the milk in its stomach a suffi- 
cient length of time for it to be absorbed before the next attack. The 
amount of food which the infant retains in the twenty-four hours is an im- 
portant factor in the treatment. In infants of from six to twelve months 
at least 600 to 750 c.c. (20 to 25 ounces) of milk should be taken and 
retained in the twenty-four hours. When the amount is lessened to 360 or 
450 c.c. (12 to 15 ounces), the infant's nutrition, as a rule, suffers to such an 



DISEASES OF THE LUNGS. 



1003 



extent that unless this amount can be increased a fatal issue is likely to 
result. 

Stimulants, in the form of brandy or whiskey, should be given early in 
the attack. Where the cyanosis is a prominent feature and the pulse is 
irregular and intermitting, small doses of digitalis should be given. In 
these cases, also, the administration of oxygen is a valuable adjunct to the 
treatment. At the height of the attack, ^\ hen the paroxysms are severe 
and especially frequent at night, the burning of cresoline in the room at 
night is in some cases beneficial. In the milder cases not accompanied by 
the more severe symptoms which I have just enumerated, belladonna or 
atropine often proves valuable. There is no drug, however, which is a 
specific for pertussis at any age. 

For older children whose health has previously been good, there is 
no especial treatment, except that they should have as much fresh air, free 
from dust, as possible, and that food should be given them after they have 
vomited. 

Where complications arise, the treatment is that of the complicating 
disease. 

In cases which are protracted, a change of air, either to the country or 
to the sea-shore at suitable seasons, is often followed by an apparent shorten- 
ing of the duration of the attack. 

Prophylaxis. — Pertussis is so highly contagious a disease, and may be 
so serious an affection in certain children, that a rigid prophylaxis should 
be enforced. It is the duty of those who take care of children with pertussis 
to see that they are isolated during the whole course of the disease. 

I have here a specimen (Fig. 142), made by Northrup, of a lung taken 
from an infant (Case 477) under one year of age, who died during a violent 
attack of pertussis. 

Case 477. Fig. 142 




Emphysema following i)ertussls. Distended alveoli often coalescing. 

The section shows extensive vesicular emphysema, with great distention 
of the walls of the alveoli. 



I have here a little girl (Case 478), four years old, who is in the fifth week of an attack 
of pertussis. 

The intervals between the paroxysms are usually one or two hours. She has just 
begun to cough, and you will have an opportunity of seeing her in one of the paroxysms. 



1004 



PEDIATRICS. 



You see that after coughing a number of times she has become decidedly cyanotic, and that 
she is aiding the expiratory effort by bending forward and placing her hands on her knees. 
After the whoop has occurred and the tenacious mucus has been expelled, she obtains 

relief. 

Case 478. 




Pertussis during paroxysm. Female, 4 years old. 

The position of the child is very characteristic, as is also the swollen 
and congested condition of her face. When this picture is once seen, and 
you have heard the characteristic whoop, you will have no difficulty in 
making the diagnosis of pertussis. 

In some cases, even in older children and where no complications are 
present, the attack of pertussis may be so severe as to prove serious. I 
saw a case of this kind in consultation with Dr. Howe, of Cohasset. 

A boy (Case 479), six years old, had had pertussis for five weeks. For two weeks 
previous to my seeing him the cough had been so frequent and so constantly accom- 
panied by vomiting that the child had been unable to retain any food. He was very much 
emaciated, and was so weak that he could not stand. This condition lasted for a week or 
ten days : he then began to improve, and finally recovered entirely. 

Asthma. — Asthma is an affection of the lungs characterized by spas- 
modic attacks of dyspnoea. The disease is rare in infancy, but is not un- 
common in childhood. 

Etiology. — The cause of asthma has not been satisfactorily deter- 
mined. There is a strong neurotic element in the disease, and in many 
cases this element is apparently hereditary. In individuals who have a 
tendency to the disease it may be incited by various causes, such as sudden 
atmospheric changes or the inhalation of irritants. 



DISEASES OF THE LUNGS. 1005 

Pathology. — There are no known pathological lesions which character- 
ize the disease. In cases of long duration the lesions of chronic bronchitis 
are often found. 

Symptoms. — The symptoms of bronchial asthma are the same in the 
child as in the adult. The onset is usually sudden, and generally occurs 
at night. A catarrhal condition of the respiratory tract, especially of 
the bronchi, commonly precedes the attack for some days. The child is 
seized with distressing dyspnoea, mainly expiratory, the respiration being 
accompanied by a wheezing sound. The face is anxious, and if the attack 
continues for some time it becomes slightly cyanotic. The respirations are 
not especially increased in frequency. The pulse is rapid, and when the 
dyspnoea is very intense it is weak. The temperature is not raised by the 
asthma, and where the paroxysm is prolonged it may become subnormal. 
The physical signs are mostly diffuse, sibilant, and sonorous rales. The 
attack may last for a number of hours, or even for days. The paroxysms 
vary in their severity, and, as a rule, are followed by considerable exhaus- 
tion. The frequency of the attacks varies ; they may occur often or only 
at intervals of months. 

Prognosis. — The prognosis of asthma with regard to the especial attack 
is good. Where the disease is not hereditary the children very commonly 
recover from it as they approach the age of puberty. In many cases the 
attacks seem to depend upon some local affection of the air-passages, and 
the cure of these local lesions will often be followed by recovery from the 
attacks of asthma. 

Treatment. — In the treatment of asthma, the nose and throat should 
be carefully examined for local diseases, as the attacks may be caused by the 
different forms of rhinitis, adenoid growths, or enlarged tonsils. The chil- 
dren should be protected from unfavorable atmospheric influences, a high, 
dry, inland air usually being better suited to them than sea air. In some 
cases, especially of a mild form, the fumes of nitre paper will give consider- 
able relief. In very severe attacks hydrate of chloral may be given, either 
by the mouth or by enemata. Antispasmodics, such as belladonna and 
lobelia, can also be used. There is no one drug Avhich will relieve the par- 
oxysms of asthma except morphine, which should be used with great caution. 
Iodide of potassium in gradually increasing doses is in some cases beneficial. 
Especial attention should be paid to the general hygiene and to the diet of 
the child. 

Periodic Catarrh (Autumnal Catarrh ; Hay Fever ; Rose Cold). — 
Closely allied to asthma is. an affection of the respiratory tract occurring 
periodically and characterized by great irritation of the mucous mem- 
brane of the eyes, nose, throat, and bronchi. The same causes that have 
been supposed to produce asthma seem to be of etiological importance in 
periodic catarrh. These attacks usually occur in the summer months, but 
are generally most severe in August and Sej)tember. 

The onset of the attack, in contradistinction to the paroxysms of asthma, 



1006 PEDIATRICS. 

is generally at some definite time of the year. The especial attack lasts 
for five or six weeks, or even longer. It is characterized by a severe acute 
catarrhal inflammation of the nose, eyes, throat, and bronchi. The coryza 
and lachrymation are in many cases excessive. As the disease progresses, the 
cough becomes very distressing, and the respirations are so impeded by the 
congested and swollen mucous membranes that sleep is interfered with, and 
the child's general nutrition is soon affected. There is no general remedy 
which controls the disease, and benefit usually can be obtained only by re- 
moving the child to a locality which is free from the causes that produce 
the disease. 

The prognosis in children is good. The local treatment of the upper 
air- passages is the most likely means of obtaining a cure. If it is left un- 
treated the disease occurs every year, so that just before the yearly attack 
begins it is well to have the children taken to the especial locality where it 
has been found that they do not suffer from the disease. In this way the 
impairment of their general health will be prevented, and it is possible that 
they will eventually cease to be affected by the disease. 

Where the child cannot be removed from an irritating locality, tempo- 
rary relief can be obtained from sprays of cocaine. As recommended by 
Wyman, the windows of the sleeping-room should be closed early in the 
evening and kept closed during the night. In this way the dust in the air 
is allowed to settle, and there is less danger that the irritating material, 
whatever it may be, will produce its effect when the child is asleep. As a 
rule, it is advisable to give the child quinine in tonic doses, beginning just 
before the date of the onset of the disease and continuing with it until the 
attack has almost run its course. 



DISEASES OF THE PLEURA. 1007 



LECTURE Iv. 

DISEASES OF THE PLEURA. 

PLEURISY. — Inflammatiou of the pleura may be acute or chronic, and 
may be accompanied by an effusion, which may be serous, sero-purulent, or 
purulent. 

Acute pleuritis, either with a simple exudation of fibrin or accompanied 
by fluid, is quite frequent in children. The effusion has a greater tendency 
to be purulent in children than in adults. It seems to follow exposure of 
various kinds and to be produced by a number of organisms. As a sec- 
ondary affection it occurs especially after lobar pneumonia and pulmonary 
tuberculosis, also in the course of the acute exanthemata and in such dis- 
eases as rheumatism. 

In regard to the micro-organisms which are supposed to produce pleuri- 
tis there is an evident difference in the intensity of the inflammation which 
follows their invasion. In the serous exudations the pneumococcus has 
been found most frequently, and seems to be most commonly present in the 
benign forms of the disease. Next to the pneumococcus the staphylococcus 
has been found to be present in the least virulent forms. The bacterium 
which has been found in the pleuritic effusions of the severest cases is the 
streptococcus. In those effusions which arise from tuberculosis the bacillus 
tuberculosis has been found. 

Pathology. — Pleuritis is usually a unilateral disease, but may in rare 
cases be bilateral. The pathological conditions found in the pleurisy of 
children do not differ from those which occur in later life. Althous^h 
localized areas characterized by the production of fibrin (dry pleurisy) are 
quite frequently found at the post-mortem examination, the diagnosis of 
this form of disease in infants and in young children is not often made 
during life. Where, however, large areas of the lung are invoh'ed in 
broncho-pneumonia, dry pleurisy quite frequently occurs, and small circum- 
scribed areas are commonly met with in connection with lobar pneumonia. 
In the common form of pleurisy, where there is a production of fibrin and 
serum (pleurisy with effusion), a greater part of the pleura of one side of 
the chest is usually involved. According to Delafield and Prudden, while 
the iuflammation is in progress the surface of the affected pleura is coated 
with fibrin, bands of fibrin stretch between the parietal and })uhuonarv 
layers of pleura, and in the pleural cavity there is serum in variable quanti- 
ties. This serum is sometimes clear, sometimes is turbid from the presence 
of pus-cells and flocculi of fibrin. Both these forms of pleurisy, although 
differing in their clinical history, are anatomically essentially the same. In 
both we find, first, the exudation of fibrin and a few pus-cells either with or 



1008 PEDIATRICS. 

without serum ; second, a gradual absorption of the serum and fibrin ; finally, 
a formation of new permanent connective tissue in the form of adhesions or 
of thickening of the pleura. Through the whole process the tissue of the 
pleura is but little changed. The products of inflammation, although they 
originate in the tissues, do not infiltrate it, but make their way to its sur- 
face, accumulate there, and undergo different changes. Variations from the 
regular course of the inflammation are caused by the excessive formation 
of the fibrin, the serum, or the pus, and by the manner in which these 
inflammatory products are absorbed. It is still, however, undetermined 
whether acute pleuritis with a serous effusion is an entirely separate disease 
in children from a pleuritis with purulent effusion, or whether the difference 
between the two diseases is merely one of degree in the amount of pus-cells 
present. Clinically there is a certain amount of evidence in favor of the 
former supposition, as an acute pleuritis with serous effusion in young chil- 
dren usually runs a definite benign course and is reabsorbed without be- 
coming purulent. Empyema in young children, on the other hand, is 
frequently, so far as can be determined, a purulent exudation from the 
beginning. It is therefore better in describing pleuritis in infancy and 
early childhood to speak of the serous effusion and the purulent effusion 
as two separate diseases. 

Symptoms. — The onset of acute pleuritis with serous effusion is in many 
cases violent, and attended by a high temperature, increased respirations, 
quickened pulse, restlessness, and even pain, which in young children is 
usually referred to the abdomen. In infants and in young children convul- 
sions are quite common, while in older children the symptoms are more like 
those which occur in adults. There is a short, painful cough, with loss of 
appetite, and frequently vomiting and diarrhoea. These early symptoms are 
usually followed in two or three days by an exudation and by a decided 
lessening of the pain and dyspnoea. At the same time the temperature 
begins to have a decided morning remission. When the exudation is large, 
the children lie more comfortably on the affected side, and when they are 
nursing they nurse most easily from the right breast if the left pleura is 
affected, and from the left breast if the right pleura is affected. After the 
serous effusion has remained for a number of days it ordinarily begins to 
lessen in amount, absorption takes place, and by the end of a week or ten 
days it becomes entirely absorbed and the child recovers. In other cases it 
becomes chronic unless its absorption is furthered by aspiration. 

The physical signs of pleurisy before the effusion has taken place are in 
infants and in young children quite difficult to detect. The friction-rub is 
often absent and the pain is difficult to locate. It is frequent, however, to 
find that there is tenderness on the' affected side on palpation and percussion, 
as the child cries more when the affected side of the chest is compressed. 

When the effusion has taken place, the chief physical signs are dulness 
on percussion, bronchial respiration, and, if the effusion is in considerable 
amount, displacement of the heart. The other physical signs, such as de- 



DISEASES OF THE PLEURA. 1009 

creased vocal resonance and fremitus, which are commonly met with in the 
pleurisy of adults, are not, as a rule, sufficiently marked in infancy and 
early childhood to be of much value for diagnosis. Great difficulty may 
arise in auscultation from the finer sounds being obscured by the child's 
crying, but in the intervals when the child takes a breath and its cry must 
necessarily cease for a moment, valuable information can be obtained by the 
quick use of the stethoscope. 

Where the effusion is sufficiently large to displace other organs, such as 
the liver and the spleen, the presence of the effusion is so evident from the 
usual signs that these displacements are not of especial value except so far as 
they show that the effusion is in large amount. After these large effusions 
have lasted for some time, and especially when they are purulent, I have 
met with decided bulging of the affected side. 

Diagnosis. — The diagnosis of pleurisy with serous effusion is to be 
made from lobar pneumonia and from empyema. The physical signs which 
in the adult are most useful in differentiating pneumonia from a pleuritic 
effusion are often misleading or absent in the young child. Thus, absolute 
dulness may occur in other conditions as well as in a pleuritic effusion, while 
bronchial respiration, such as is heard over a consolidated lung, may also 
be heard over a large effusion. The vocal fremitus may be absent in a 
pneumonic consolidation, and sometimes, though rarely, well marked over 
an effusion. Moist rales have been heard in children over an effusion, and 
fluid has been aspirated at a point where a friction-rub was heard. It is 
well known, also, that aspiration is not a conclusive means of diagnosis, for 
punctures have often been made where an effusion was present and yet no 
fluid was obtained. The change in the level of the effusion on change in 
position is of some value in diagnosticating a pleuritic effusion from pneu- 
monia, but is often difficult, and at times impossible, to determine in young 
children. The most reliable means of diagnosis in infancy and in early 
childhood is percussion. The area of dulness which occurs in lobar pneu- 
monia is quite different from that which is found in cases of effusion un- 
complicated by previous adhesions. If adhesions are present, these typical 
changes are so interfered with that the percussion becomes as unreliable a 
sign as the others which I have just mentioned. The younger the indi- 
vidual, however, the less likely are extensive adhesions to be present, and 
the more valuable, therefore, is the evidence of an effusion given by per- 
cussion. As has been shown by Whitney, when the effusion is small there 
is absolute dulness (flatness) at the base of the thorax. A friction-sound 
may be heard over the dull area, and respiration may be quite distinct, 
and sometimes accompanied by rides. Under these circumstances the diag- 
nosis of the condition as one of effusion must depend upon the outline of 
the area of dulness. In determining these small areas of dulness the 
lower border of the two sides of the thorax must first be carefully com- 
pared by percussion, bearing in mind that the lower border of the pulmo- 
nary resonance in early life corresponds to the position of the ninth doi'sal 

64 



1010 PEDIATRICS. 

vertebra on the right side and to that of the tenth dorsal vertebra on the 
left, as I have already explained to you in my lecture on development 
(page 122). 

You must always remember that the percussion of an infant's or a 
young child's chest should be very light, as heavy percussion, owing to the 
delicacy of the thoracic walls in early life, is unreliable. 

Palpatory percussion, for the same reason, gives more information when 
the child is crying than can usually be obtained by the sound, but, as I have 
said in describing the auscultation in these cases, quick percussion in the 
intervals of respiration is also a valuable aid to diagnosis. 

Extended observations have been made on the line of percussion-dulness 
found in medium effusions by Ellis and Garland, and lately in small effu- 
sions by Whitney, of Denver. These investigators have shown that as an 
effusion increases in quantity its upper border undergoes a gradual series 
of changes, provided there are no adhesions. 

Where the effusion is small in amount it can usually first be detected in 
the back. In these small effusions the upper border of absolute dulness 
begins at the vertebral column, extends outward horizontally for a distance 
which varies according to the size of the effusion, and drops in the neigh- 
borhood of the posterior axillary line by a curve more or less abrupt to the 
base of the thorax. As the effusion increases in size the line of dulness 
drops more anteriorly. Where the effusion is moderate, as where the lower 
half of the pleura is filled, in some cases, but not usually, a slight dis- 
placement of the heart may be noticed, and the percussion over the slightly 
compressed lung may give tympanitic resonance. The upper border of the 
area of dulness in these medium effusions is found to extend at first outward 
and then upward over the angle of the scapula, reaching its highest point 
in the axillary region. The line may then drop abruptly from the upper 
axilla to the base of the thorax near the apex of the heart. This line, 
which has been called the " letter S" curve, is characterized by having its 
highest point in the axillary line. When the quantity of fluid is still larger 
and exceeds a certain amount, the " letter S" curve is obliterated, and the 
resonance over the compressed lung becomes less marked. The displace- 
ment of the heart in this latter case is a most valuable sign of effusion in 
young children, and with careful, light percussion the gradual increase and 
decrease of the effusion where it is of any great extent can be determined by 
cardiac percussion. 

You must always bear in mind the physiological dulness of the heart 
which I have already described as occurring in early childhood (page 123) 
under the lower third of the sternum. This dulness, however, is relative, 
and becomes much more marked and absolute where it is caused by a 
displaced heart. 

The differential diagnosis from lobar pneumonia is greatly aided by 
understanding these areas of percussion-dulness which I have just described. 
Thus, where the diagnosis is to be made between pneumonia of a lower lobe 



DISEASES OF THE PLEURA. 1011 

and a small or medium pleuritic effusion, where an effusion is present the 
dulness will be in the lower part of the thorax, with normal or tympanitic 
resonance above it; where pneumonia is present the area of dulness will 
often correspond to the boundaries of the lower lobe only. In like manner 
the area of dulness of the effusion will differ in the axillary regions and in 
the front of the thorax from the areas of dulness produced by the consolida- 
tion of the different lobes of the lung. 

The diagnosis from empyema is very difficult, as the younger the indi- 
vidual the more likely are the effusion to be purulent and the early symp- 
toms to be similar to those of the serous form of exudation. After the first 
week or ten days of the disease, however, where the effusion is purulent, 
the usual signs of absorption which so commonly occur in a serous effu- 
sion are ordinarily not found, and aspiration of the pleural cavity will then 
determine which form of the disease is present. 

Where no bacteria are found in the fluid, where there is no history of a 
preceding acute pneumonia or a neoplasm of any kind, or where there is 
little tendency to absorption of the exudate, and where the exudate is found 
to contain blood, the failure to find bacteria in the exudate may be regarded 
as pointing strongly towards a tubercular origin. 

Prognosis. — The prognosis of a serous effusion, as a rule, is very favor- 
able in infants and in young children unless one of the more virulent forms 
of the pyogenic cocci is present, or unless the disease is secondary to tuber- 
culosis elsewhere and is caused by the bacillus tuberculosis. If the serous 
effusion tends to become purulent, the prognosis is not so good, but still, 
provided appropriate treatment is carried out, it is favorable. If, as in 
rare cases, the pleuritic effusion occurs on both sides, the prognosis becomes 
grave. The possibility of the presence of tubercle should be considered in 
these latter cases. 

I have had in my service at the City Hospital a hoy (Case 480), thirteen years old, 
who was attacked with pleuritis and a serous effusion of the left side with displacement of 
the heart to the right. After one aspiration the fluid was quickly absorbed, hut three 
weeks later he was attacked with pleurisy on the right side, followed by an efl'usion and 
displacement of the heart to the left. This eflusion was absorbed without aspiration, and 
the boy was discharged from the hospital well and strong, with both lungs apparently in a 
normal condition. 

Where the effusion is very large and the heart is much displaced, there 
is always the danger of a fatal issue from asphyxia, and the prognosis de- 
pends upon whether the effusion can be controlled by aspiration and the 
heart thus be kept in normal position. A case which illustrates the danger 
of these large effusions accompanied by displacement of the heart came 
under my care at the Children's Hospital : 

A boy (Case 481), four or five years old, entered the hospital with a large efl'usion in 
the left chest. The heart was displaced to the right, and upward as far as the second 
interspace to the right of the sternum. He was cyanotic and gasping. On aspirating the 



1012 PEDIATRICS. 

chest and removing a large quantity of fluid, the heart reassumed its normal position under 
the sternum. On the following night the boy died suddenly, the effusion having rapidly 
accumulated and having again displaced the heart. 

Cases of this kind should warn us that a pleuritic effusion of any extent 
in a young child should be watched continuously, and that aspiration should 
be performed where there is indication of an increase in the intrathoracic 
pressure. 

Where the pleurisy is secondary to other diseases, such as rheumatism 
and scarlet fever, the prognosis is not so favorable : the effusion is not apt 
to be absorbed so readily, and is more likely to become purulent. The 
prognosis is also rendered more unfavorable in these cases by the prolonged 
pressure upon the lung, with its corresponding ill effects upon the general 
condition of the child. The dangers which arise from the development of 
tuberculosis must also be borne in mind. 

Treatment. — The treatment of pleuritis during the early days of the 
attack, before an effusion of any considerable extent has appeared, should 
be directed to the relief of the pain by a flannel bandage closely applied to 
the thorax, so as to allow the ribs to move as little as possible in respira- 
tion. Sometimes an occasional dose of tinctura opii camphorata will also 
be needed to make the child comfortable. After the effusion has increased, 
the child should, if possible, be kept in bed. There are some cases, how- 
ever, where a child with a considerable effusion in its pleura will feel well 
and bright, and will play about its nursery without showing any especial 
symptoms of discomfort. I have met with instances of this kind where, 
excepting that it was pale and had a poor appetite, the child seemed bright 
and active, and yet it had a pleuritic effusion large enough to displace the 
heart. 

In mild cases, after the effusion has attained its maximum, you should 
carefully examine the child each day, to see whether there is a rapid increase 
in the fluid, which by displacing the heart and causing dyspnoea would 
render necessary immediate relief, or whether the fluid has begun to be 
absorbed. In the latter case an expectant treatment is all that is required. 
In the former case, or if absorption of the fluid is delayed for two or three 
weeks, the chest should be aspirated. A bacteriological examination of the 
fluid removed should then be made, to determine which form of organism 
is present in the exudate. If one of the more benign forms of bacteria is 
present, such as the pneumococcus, or if the fluid is found to be serous, no 
further treatment will be required, unless there be a reaccumulation of the 
fluid, in which case a second aspiration will be indicated. If, however, 
the streptococcus is found in the exudate, the case must be watched very 
carefully, as it is more likely to become purulent and to need radical treat- 
ment. 

As the unfavorable symptoms in a pleuritic effusion arise mostly from 
intra-thoracic pressure, relief from the pressure by aspiration is indicated 
rather than by the use of drugs, which cannot be depended upon. 



DISEASES OF THE PLEURA. 1013 

The point of aspiration should usually be in the fourth or fifth inter- 
space in the axillary line, or a little farther back. 

Purulent Pleuritis (Empyema). — Empyema is a purulent effusion into 
the pleural cavity. In the first three or four years of life it is much more 
common than a serous effusion. 

The cause of these purulent effusions is the same, so far as we know, 
as that of serous effusions. The same organisms are present in the two 
forms, and they are also frequently present when purulent pleurisy is 
secondary to a number of diseases, the most prominent of which is lobar 
pneumonia. 

Usually the whole pleura is involved, encysted empyemas in infants and 
young children being rare. 

The disease when primary may be acute in its onset, and may simulate 
closely the initial stage of lobar pneumonia. In other instances it is slow 
and somewhat insidious in its development. The pulse and respirations 
may be quickened, but after the early days of the disease they are often 
very little raised. There is nothing characteristic in the temperature of an 
empyema, and the diagnosis usually can be made only from the knowledge 
that the younger the individual the more likely is pus to be present. This, 
however, can be determined definitively only by means of the aspirator. 

The physical signs are the same as in a serous effusion. The absorption 
of a purulent exudate without surgical interference is very rare. I have 
occasionally met with cases where one aspiration was all that was necessary, 
and where, seemingly, complete absorption took place. 

Where cases of empyema are left untreated, a spontaneous opening 
usually takes place through some portion of the thoracic walls, but the 
exudate may also find its exit through the lungs by opening into one of the 
bronchi or perforating in other directions. I have met with cases where the 
diaphragm was perforated and the point of exit of the pus was in the region 
of the umbilicus. Where perforation does not occur, the pus is partially 
absorbed, adhesions are formed, and sometimes great deformity of the chest 
follows, which may result in a marked degree of lateral curvature of the 
spine as well as in great contraction of the chest. 

After the first aspiration, unless absorption occurs within a week, and 
especially if one of the more virulent forms of bacteria is found in the 
exudate, a radical operation is the best method of treatment. Where this is 
performed early in the disease, the prognosis is very good in infancy aud 
early childhood, unless the empyema is of a virulent form or is secondary 
to some incurable disease, such as is caused by the bacillus tuberculosis. 
The pleural cavity should be thoroughly drained by means of drainage-tubes. 
In many cases, especially in children over two or three years of age, resec- 
tion of one or two ribs gives the best results. Although in some cases a 
rapid cure in two or three weeks follows the operation, yet the recovery is 
often prolonged for many months, even where strict antiseptic precautions 
have been taken at the time of the operation. 



1014 



PEDIATKICS. 



As the treatment of empyema is essentially surgical, I shall not enter 
into its details. 



This little girl (Case 482), eleven years old, was attacked six weeks ago with a chill 
followed by vomiting. She then had a short, dry cough. For the past few days she has 
complained of pain in the lower part of the right chest. She has been feverish, has lost in 
weight and in appetite, and her respirations have been painful. She lies most comfortably 
on her back and on her left side. A pleuritic friction-rub has been heard in the right 
axillary region. Her lips and cheeks are slightly cyanotic. 

Case 482. 




Acute pleurisy with serous effusion. Female, 11 years old. The line of the upper border of the effusion, 
the area of cardiac dulness, and the margins of the ribs are marked in black. 



Her tongue is somewhat coated. The alas nasi are working, and, as you see, the dys- 
pncea is so marked that she has to sit almost upright in bed. The percussion and ausculta- 
tion of the left lung show nothing abnormal. The resonance is fair over the upper part of 
the right front and back. There is absolute dulness from about the fifth dorsal vertebra in 
the right back to the base of the lung. This dulness extends into the axillary region, where 
it reaches its highest point, and then gradually descends to the right parasternal line on a 
level with the fourth costal cartilage. Over this area of dulness respiration is markedly 
diminished. No friction-rub is heard. The vocal and the tactile fremitus are diminished. 
The impulse of the heart is found in the fourth interspace, 1 cm. (f inch) to the left of the 
mammary line. The heart-sounds are normal. There does not appear to be any displace- 
ment of the liver. An examination of the urine shows it to be acid, to have a specific 
gravity of 1022, to be of normal color, and to contain no albumin. The chlorides are nor- 
mal. The physical signs are those of a pleuritic effusion of the right side with displacement 
of the heart to the left. 

(Subsequent histor3^) During the following week the area of absolute dulness gradu- 
ally decreased, and an exploratory aspiration showed the fluid to be serous. Three weeks 



DISEASES OF THE PLEURA. 



1015 



from the time when she entered the hospital, and nine weeks from the beginning of the 
attack, the dulness on percussion gradually disappeared, auscultation showed the respiration 



















CHAET 42. 


(Case 


482 


) 


















Days of Disease. 




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103 
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40.5° 
40.0 
39.4 
38.8° 
38.3 
37.7° 
37.2 
































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110 

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80 

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45 
40 
35 
30 
25 
20 
15 
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Acute pleurisy -with serous eflfusion. Female, 11 years old. 



to be normal, and the heart resumed its normal position. This chart (Chart 42) shows the 
temperature, pulse, and respiration while she was in the hospital. 



1016 



PEDIATRICS. 



This chart (Chart 43) shows the temperature for twenty-one days in a case (Case 483) 
of serous effusion in the pleura, where in the beginning 165 c.c. (5J ounces) of fluid were 
withdrawn from the chest. 

CHART 43. (Case 483.) 





Days of Disease. 




F. 












































c. 


107° 
106 
105 
104 
103 
102 
101° 
100° 
99 

98 
97 
96° 
95 


ME 


M E 


M E 


M E 


M E 


M E 


ME 


M E 


ME 


ME 


ME 


ME 


ME 


M E 


ME 


ME 


M E 


M £ 


M E 


M E 


ME 


41.6° 

41.1° 

40.5° 

40.0° 

39.4° 

38.8° 

38.3° 

37.7° 

37.2° 
37.0° 
36.6° 

36.vl° 

35.5° 
35.0° 




















































































































































































































/ 


A 




































/ 






v 






/ 








/ 


/ 




y 














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^ 


/ 


/ 




^ 




/ 


/ 


/ 


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r 














V 



















































































































































































= 



Acute pleurisy with serous effusion. Male, 4 years old. 

The fluid reaccumulated, so that absolute dulness was found over the whole right side 
of the chest in front and behind, but aspiration did not have to be resorted to again, and 
complete absorption took place thirty days from the beginning of the attack. 

A number of cases have been reported in which a purulent effusion has 
been treated by aspiration and has seemingly disappeared entirely without a 
radical operation. These cases should be borne in mind when treating 
purulent pleuritic effusions. An infant (Case 484), seven weeks old, with 
empyema, at the Boston City Hospital, in the service of Dr. Doe, recovered 
entirely after one aspiration. 

The initial stage of empyema often closely simulates pneumonia. 

A case illustrating this fact has come under my observation, where a boy (Case 485), 
three years old, and previously well, was attacked with pain in the left side, with a chill and 
with dyspncea. A physical examination made on the third day of the attack showed the 
right lung to be normal. On the left side of the chest there were absolute dulness, dimin- 
ished respiration, and increased vocal resonance, and fine rales were heard from the fifth rib 
to the base of the lung, both in front and behind. Two days later an exploratory aspiration 
showed that the physical signs were caused by an empyema. 

Another case which illustrates the difficulty in diagnosticating a puru- 
lent effusion in the pleura in the early days of the disease is the following : 

A girl (Case 486), four years old, was suddenly attacked with cough, and pain in the 
right side. The temperature was 40.5° C. (105° F.). The respirations were quickened, and 
the pulse was rapid. Nothing abnormal was detected on physical examination. On the 
following day the general symptoms disappeared, and the temperature fell to 38.8° C. 
(102° F.). In another day the temperature fell to 37° C. (98.6° F.), and the child seemed 



DISEASES OF THE PLEUEA. 



1017 



bright and well. On the following day, however, the temperature rose to 40° C. (104° F.), 
absolute dulness was detected in the right axillary region, and an exploratory aspiration 
showed the presence of pus. 

Here is a little girl (Case 487), three years old, who two years ago had an attack of some 
pulmonary disease accompanied by fever. Since then she has been delicate and has coughed 
a great deal. Her cough has increased in the last few weeks, but she has not lost in weight 
nor had any other abnormal symptoms. She is pale, and the cervical, axillary, and inguinal 
glands are enlarged. Her fingers are markedly clubbed. She shows a peculiar lateral 
curvature of the spine, which cannot be made to disappear by traction. The right side 
of the thorax expands normally, the left side scarcely at all. There are hyperresonance 
over the right lung, no rales, and compensatory respiration. The left lung is apparently 
atelectatic, and shows dulness everywhere except in a small triangular area at the inferior 
angle of the scapula. This deformity of the thorax is probably the result of an empyema 
which occurred two years ago and was not properly treated. 

Here is an infant (Case 488), one and a half years old, who entered the hospital with 
a history of an acute attack, characterized by fever, cough, and dyspnoea. Physical exam- 
ination showed nothing abnormal on the left side of the chest, but on the right side there was 
absolute dulness, with bronchial respiration. No rales were heard anywhere in the lung. 

The upper border of the area of dulness I have marked with a black curved line, and 
you see how, beginning at about the fourth dorsal vertebra, it gradually rises as it approaches 
the axillary line and then falls as it approaches the right parasternal line. The child's 

Case 4S9. 




Recovery from empyema. Male, 10 years old, showing scar eight years after operation. 



right arm has been turned upward and forward, in order that the ribs shall be sufficiently 
separated for the introduction of the trocar preparatory to an operation for the radical cure 
of the empyema. An exploratory aspiration has already shown the presence of a purulent 
eflusion in the pleura. 

(Subsequent history.) The child was operated upon by Dr. Burrell, an incision being 
made in the mid-axillary line on the right side, and about 1.4 cm. (i inch) of the seventh 



1018 



PEDIATRICS. 



rib was resected. Nearly two quarts of pus were evacuated, and the pleural cavity was 
washed out with a boracic acid solution, a drainage-tube inserted, and a baked dressing 
applied. 

This picture (Case 488, II.), taken some months later, shows the scar which was left 
after the operation. 

This boy (Case 489, page 1017), ten years old, had a purulent eflusion on the right 
side when he was two years old. 

On entering the hospital with a history of having been sick for a number of weeks, 
there was found to be absolute dulness over the whole right side of the chest, with displace- 
ment of the heart to the left. Aspiration showed the dulness to be produced by a purulent 
eflPusion in the pleura. I made a permanent opening, and after thirty-six days the boy re- 
covered, and was discharged from the hospital with the lung apparently normal. I show 
him to you to-day in order that you may see how the scar looks after a number of years. 
You see that the right side of the chest is equally expanded with the left, and that no de- 
formity has resulted from an extensive empyema. 

















CHAKT 44. 


(Case 


489. 


) 


















Days of Disease. 




F. 












































c. 


107 
106 
105 
104 
103 
102 
101 

100 

99 

NORMAL 
TEMPO 

98 

o 

97 

o 

96 

95 


M E 


M E 


M E 


M E 


ME 


M E 


M E 


M E 


M E 


M E 


M E 


ME 


ME 


M £ 


M E 


M E 


M E 


M E 


ME 


MJE 


M E 


41.6 

41.1 

40.5° 

40.0° 

39.4° 

38.8 

38.3° 

37.7° 

37.2 
37.0 
36.6 
36.1 

35.5 
35.0 






































































































































































































/ 










/ 


/ 






A 
























/ 










/ 


y 


/ 


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/ 


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/ 


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Purulent pleuritis. Male, 2 years old. 



This chart (Chart 44) shows the temperature during the twenty-one days previous to 
the removal of the drainage-tube. 



DIVISIOI^ XVII. 

DISEASES OF THE HEART AND PERICARDIUM. 



IvKCTURK IvI. 

DISEASES OF THE HEART. 

Cardiac disease in infancy and early childhood may be divided into 
congenital or acquired^ developmental or inflammatory, functional or organic, 
acute or chronic. In this early period of life cardiac disease has certain 
characteristics in which it differs essentially from those which are met with 
in later life. One of these characteristics is that there is a more decided 
tendency to recovery than at a later period. Another is that, owing to the 
undeveloped condition of the infant and young child, interference with the 
growth of other organs and parts of the body may more easily result from 
diseases connected with the circulation than is possible in the case of the 
fully-developed adult. Thus, there are certain anatomical facts connected 
with the ossification of the sternum which become of great importance in 
connection with cardiac disease. Deformities of the thorax may result from 
the continued pressure of the enlarged heart on the soft and pliant sternum 
and costal cartilages of the young subject. These deformities do not arise 
merely where the individual is rhachitic, but may also depend upon the 
stage of development at which the cardiac disease begins. The deformity is 
more or less pronounced in inverse ratio to the age and in direct ratio to the 
time during which the cardiac disease has existed. The shape and extent 
of the deformity are also dependent on the degree of ossification which has 
taken place in the sternum. In young infants, where the entire sternum, as 
I have described in a previous lecture (page 71), is in a cartilaginous condi- 
tion, the intra-thoracic pressure from an enlarged heart may cause a bulging 
of the whole front of the thorax. This may occur during the first year, 
and even up to the third year. As the child grows older, the manubrium 
and the second piece of the sternum become ossified and offer more resist- 
ance, while the third piece of the sternum, still remaining in a semi-cartila- 
ginous condition, may be tilted. This may occur in children in whom the 
cardiac disease has not developed until the fourth, fifth, or sixth year. I 
have had under my care a child seven years old who at the age of five yeai^s 

1019* 



1020 PEDIATRICS. 

had articular rheumatism with resulting cardiac hypertrophy, and who 
presented this displacement of the third piece of the sternum. No other 
signs of rhachitis were detected. The middle period of childhood is also 
a peculiarly unfortunate one for the occurrence of cardiac disease, because 
the heart grows so rapidly at this period that it requires a proportionately 
greater amount of intra-thoracic space for the normal performance of its 
function than it does later. 

In addition to the injury which may be done to the thoracic walls by an 
enlarged heart, we must consider the interference with the normal uniform 
expansion so necessary for the growing pulmonary tissue, and the consequent 
loss of the elasticity which plays so prominent a part in the establishment 
of the equipoise which should exist in a perfected respiratory apparatus. 

The occurrence of diseases of the blood-vessels is rare in infancy and early 
childhood in comparison with later life. Aneurism is rare. A narrowing 
of the isthmus aortse is more common, and is one of the most marked of 
the congenital defects of the blood-vessels. Sometimes there is an absence 
of the isthmus aortse during foetal life. The compensation for this defect 
takes place by an increased action of the left ventricle and the establishment 
of a collateral circulation between the subclavian artery and the thoracic 
and the abdominal aorta. These malformations exert in varying degrees 
an influence on the heart, as the infant grows older, from increased blood- 
pressure. 

CONGENITAL DISEASES OP THE HEART.— Congenital diseases 
of the heart are somewhat obscure in their etiology, but usually they result 
either from an interference with the normal development of the organ or 
from endocarditis, or from a combination of both. In order to understand 
these congenital lesions you must remember the chief points in the mechan- 
ism of the foetal circulation, which I explained to you in a previous lecture 
(page 19). I then told you that the parts of the foetal circulation at birth 
which were of most importance in reference to diseased conditions of the 
heart and great blood-vessels later were the foramen ovale and the ductus 
arteriosus. I also told you at what period after birth they disappeared. 
Where these remains of the foetal circulation, which are normal during 
intra-uterine life and for a short period afterwards, continue as the infant 
grows older, they become abnormal and interfere with the equilibrium of 
the circulation. 

Where the development of the heart has been interfered with in intra- 
uterine life, there results another set of malformations, the chief of which 
are an open ventricular septum, a transposition of the great vessels con- 
nected with the heart, and various malformations of the valves of the heart. 
Where, again, an inflammatory condition has taken place in intra-uterine 
life (foetal endocarditis), various other morbid conditions result, the most 
common of which are connected with the pulmonary artery, causing stenosis 
or atresia, a narrowing of the conus arteriosus, and various malformations 
of the tricuspid valve and other orifices of the heart. 



DISEASES OF THE HEART. 



1021 



The form of inflammation of the endocardium which occurs in intra- 
uterine life is the chronic or sclerotic variety. Yerrucose endocarditis is 
rare. (Osier.) 

A deficient filling of the left side of the heart in early life, such as 
occurs in cases of atelectasis, foetal pneumonia, or foetal endocarditis, espe- 
cially where stenosis of the pulmonary artery has resulted, may delay the 
closure of the foramen ovale and of the ductus arteriosus, which under these 
circumstances act as safety-valves. This is true also of the delay in the 
closing of the intra- ventricular septum, which is often of great aid in pre- 
serving the equilibrium of the circulation. In congenital cardiac disease it 
is usually the right side of the heart that is affected. The most common 
congenital cardiac lesions are an affection of the pulmonary artery, an open 
foramen ovale, an open ventricular septum, and an open ductus arteriosus. 

The lesions most commonly found in connection with the pulmonary 
artery are stenosis of the pulmonary orifice, atresia of the orifice and of 
the artery, and stenosis of the conus arteriosus. Stenosis of the pulmonary 
orifice usually results from foetal endocarditis, though it is possible that it 
may be the result of faulty development. The complete obliteration of the 
orifice of the beginning of the pulmonary artery is common, though not so 
frequent as stenosis of the orifice, and is probably of developmental origin. 

I have here a specimen (Fig. 143) which was taken from a child (Case 
490) with congenital cardiac disease under the care of Dr. Northrup. It 
illustrates this malformation of the pulmonary orifice. 

Fig. 143. 




Congenital cardiac disease. Male, 4>^ years old. Right and left ventricles laid open by two cuts. 
Stenosis of pulmonary orifice. Incomplete septum ventriculorum. 1 and 1', septum ventriculorum cut 
across ; 2, aortic valves ; 3, probe passing through narroAved pulmonary orifice ; 4, bent probe passing 
through, right ventricle to left through opening in septum ventriculorum. 

The specimen was taken from a boy four and a half years old, who during 
life had shown cyanosis, clubbed fingers, and at times severe dyspnoea. The 
physical signs in connection with the heart were a fine wave perceptible to 
the eye at the left third interspace, a soft, purring thrill over the base of the 
heart, cardiac pulsation 1.4 cm. (J inch) outside of the left mammary line, 
and cardiac dulness from the right sternal margin to the left mammary Une, 



1022 



PEDIATRICS. 



with no dulness to the right of the sternum. A loud, harsh systolic mur- 
mur was heard over the left margin of the sternum, most marked at the 
second left interspace and third rib, and not transmitted to the left or along 
the aorta. 

The pulmonary artery was abnormally small, the aorta was abnormally 
large, the conus arteriosus was practically obliterated at the pulmonary 
orifice, and the ventricular side formed a ring of white cicatricial tissue J 
cm. (J inch) in diameter. 

Here is a specimen (Fig. 144) of the same heart with the apex cut away 
so as to show the relative thickness of the ventricular walls and the greatly 
thickened septum ventriculorum. 

¥m. 144. (Case 490.) 




Transverse section of heart near apex.— 1, right ventricle ; 2, left ventricle. 



The right ventricle is markedly hypertrophied. The left ventricle is 
normal. The ventricular septum is greatly hypertrophied. In this case the 
ductus arteriosus was impervious and the foramen ovale practically closed. 
A foetal endocarditis had taken place before the septum ventriculorum had 
closed. Thp endocarditis caused contraction of the conus, and the blood 
being forced from the right ventricle through the imperfect septum pre- 
vented the latter from closing. This provided a safety-valve, which, as 
usually happens in this form of malformation, allowed the child to live 
longer than is common in other congenital cardiac malformations. The 
aorta, receiving a direct stream from both ventricles, was distended; the 
pulmonary artery, receiving but little, remained small. It is interesting 
to note in this case that the child passed through an attack of pertussis 
and measles without serious results. It died ultimately of abscess of the 
brain. 

There may also be dilatation of the pulmonary artery, as in a case 
reported by King, where the pulmonary veins united to form a trunk of the 
same size as the artery and emptied into the right auricle. In this case 
cyanosis and cough were present at times, and there was oedema of the face, 
hands, and feet. There was also icterus, apparently arising from cirrhosis 
of the liver, which was present. 

Premature closure of the foramen ovale has been met with, but is ex- 



DISEASES OF THE HEART. 



1023 



tremely rare. I have already shown you this specimen (Fig. 6, page 42) of 
an infanf s heart with an open foramen ovale. 

Here is another specimen (Fig. 145), which shows a small opening in 
the ventricular septum. 

Fig. 145. 



A'' 




S, unclosed ventricular septum. Female, 10 months old. Warren Museum, Harvard University. 

In this case there was also an open foramen ovale, but no other malfor- 
mation. The infant, after showing the usual progressive signs of congenital 
cardiac disease, died suddenly. There was no history of cyanosis. 

The fourth common congenital cardiac imperfection, an open ductus 
arteriosus, which I have just referred to, is shown in this specimen (Fig. 
146, page 1024). 



This heart, which has been left attached to the lung, was taken from an infant (Case 
491), sixteen days old, who was apparently healthy at birth and presented no symptoms 
of cardiac disease. 

"When the infant was five days old it was noticed that it would sometimes become 
slightly cyanotic. At this time its temperature rose to 39.4° C. (103° F.). A physical 
examination showed nothing abnormal, and nothing abnormal was seen on inspection. 
The area of cardiac dulness was normal, and no murmurs were detected. A day or two 
later the temperature became normal ; the cyanosis increased somewhat, but was inter- 
mittent and of a very slight degree. At times the skin would become cool. A few days 
later there was slight intestinal disturbance. "When sixteen days old, without any other 
symptoms having developed, the infant died suddenly. The post-mortem examination 
made by Dr. Cutler showed this widely open ductus arteriosus. The foramen ovale is also 
open. There are no other lesions, such as stenosis of the pulmonary artery, open ventricu- 
lar septum, or lesions of the valves. The heart is of normal size. As you see, there are no 
signs of the obliterative endocarditis usually found at this age in the ductus arteriosus. 



1024 PEDIATRICS. 

The ductus arteriosus, as I have explained to you in a previous lecture 
(page 21), should gradually be obliterated within the first two weeks of 
extra-uterine life. Interference with this normal involution is not very 
uncommon, rarely occurs alone, and is usually found in connection with 
lesions of the pulmonary artery or narrowing of the isthmus aortse. Some- 
times the process of obliterative endarteritis, which has been shown by Dr. 

Fig. 146. 









D, open ductus arteriosus. Male, 16 days old. Warren Museum, Harvard University. 

J. C. Warren to be the method by which the closure of the lumen of the 
ductus arteriosus is accomplished, extends to the aorta and causes stenosis 
of the isthmus aortse. Again, the duct, in closing and retracting, pulls the 
aorta and tends to narrow that vessel, thus increasing the arterial tension. 
During foetal life stenosis of the isthmus aortse does not produce much dis- 
turbance in cases where the ductus arteriosus can carry the blood to the 
descending aorta. At birth, however, in these cases, unless the ductus 
arteriosus remains pervious, serious symptoms arise, and, if life be pro- 
longed, hypertrophy of the left ventricle takes place, and the arterial blood 
has to be conveyed to the descending aorta by means of a collateral circula- 
tion which is established between the branches of the subclavian arteries 
and the branches of the thoracic and abdominal arteries. Premature closure 
of the ductus arteriosus during foetal life has been met with, but is a rare 
condition. Very rarely the ductus arteriosus may be entirely absent. 

Imperfections of the tricuspid orifice are more rare. Lesions of the 
mitral valve are very rare in intra-uterine life. Those of the aortic orifice 
are rare in comparison with those of the pulmonary orifice, but are of the 
same nature, — that is, they may be developmental or inflammatory. 



DISEASES OF THE HEART. 1025 

The duration of life where there are intra-uterine lesions of the aortic 
orifice is not nearly so long as where the pulmonary artery is affected. 

Transpositions of the aorta and pulmonary artery are very commonly 
met w^ith in connection with other congenital defects, such as spina bifida 
or hydrocephalus, but may occur in infants who are otherwise normally 
developed. In these cases the duration of life is almost invariably short. 

Lesions of the valves vary greatly in their extent and kind. 

On the boundary line between developmental and inflammatory condi- 
tions of the heart is a class of cases in which small hsematomata are found 
on the valves. These haematomata appear just before or just after birth, 
and in the process of disintegration through which they pass may cause a 
contraction of the valvular tissue, and thus eventually produce the same 
symptoms that usually result from the more common valvular imperfections. 

Although these various abnormal conditions may be found alone, yet 
they generally occur in combination with each other, and all kinds of trans- 
positions and malformations of the vessels are at times met with. 

There are various malformations of the heart which occur at an early 
period of foetal development, and which are of pathological rather than 
clinical interest. Of these I might mention cases where there are one 
auricle and one ventricle {cor biloculare) or one ventricle and two auricles 
(coj- triloculare), as well as a case v/hich has come under my notice, where 
the heart had a double apex, the right apex lying in the fourth interspace 
to the right of the sternum, and the left apex lying in the fourth interspace 
to the left of the sternum. 

Symptoms. — Although in some cases the symptoms of congenital cardiac 
disease are very indefinite, and the disease may be masked for a number 
of months, yet in a large number of cases they soon become evident. The 
typical symptoms of congenital cardiac disease are cyanosis and attacks of 
dyspnoea amounting at times to suffocation and atrophy. As the disease 
progresses, the fingers often become club-shaped, the nails blue, and the skin 
cool. In connection with these rational signs there is usually an evident 
pulsation in the cardiac region, with bulging of the prsecordia. Where the 
obstruction caused by the lesions is sufficient to produce hypertrophy and 
dilatation of the heart, an increase in the area of cardiac dulness is found. 
Diffuse cardiac murmurs are heard often over the Avhole chest, but usually 
have their maximum intensity towards the upper part of the sternum, and 
are commonly systolic in time. 

The most common symptom is cyanosis. Remember that cyanosis may 
arise from incomplete oxygenation of the blood, and not merely I'rom the 
mixture of the venous and arterial currents. Where cyanosis is present to 
any extent there is usually some malformation of the pulmonary artery or 
its valves. Well-marked congenital malformations may be present with no 
symptoms whatever. There may be an entire absence of cyanosis ; there 
may be no increased area of duhiess and no murmurs ; and I have met with 
instances where the infants seemed to be thriving, and showed neither labored 

65 



1026 PEDIATRICS. 

breathing nor physical signs of disease up to within a few hours of death, 
and yet where a number of cardiac malformations were found at the autopsy. 
Although, as a rule, the symptoms occur at a very early period of extra- 
uterine life, yet quite frequently they are so mild in their character that 
they are not noticed especially, as is the case when they appear only when 
the infant is much excited or is crying. Again, the cardiac symptoms may 
not be prominent enough to attract attention until the infant is old enough 
to exert itself sufficiently, as by creeping or walking, to interfere with the 
equilibrium of its circulation. At times another disease, especially bron- 
chitis or pneumonia, may precipitate the cardiac symptoms. Again, it is 
quite common for endocarditis to develop in a heart in which a congenital 
malformation is present, and the diagnosis between a congenital and an 
acquired cardiac affection then becomes necessary, and is accompanied by 
many difficulties. As an illustration of how congenital cardiac disease can 
be masked for a number of weeks, I shall report to you a case which has 
lately come under my care. 

This infant (Case 492) was apparently healthy at birth, and a careful physical exami- 
nation showed nothing abnormal in the thorax. There was no cyanosis noticed, the skin 
being of a normal color. When it was sixteen days old it refused to take the breast, and 
in the afternoon seemed somewhat cold, was slightly cyanotic, and had a temperature of 
35.2° C. (95.5° F.). An examination of the heart detected nothing abnormal. A few 
drops of brandy were given to it, and after several hours the skin became warm, the respi- 
rations normal, and it took its food as usual. Early in the following morning the quick- 
ened respiration returned, the temperature rose to 37.7° C. (100° F.), it refused to take its 
food, failed rapidly, and died in the afternoon. 

The examination of the heart by Dr. Mallory showed a large open foramen ovale and 
an absence of the upper part of the intra-ventricular septum below the aortic valve. The 
beginning of the aorta for a distance of 1 cm. (f inch) was dilated into a spherical pouch, 
from which were given off (1) the aorta without any branches before the intercostals, thus 
supplying only the lower part of the body, (2) a large vessel to the right lung, and (3) a 
large vessel to the left lung. From the upper part of the right ventricle was given off a 
large vessel which divided 1.4 cm. (^ inch) above the pulmonary valve into a large vessel 
on the right side and two smaller ones on the left. The large vessel apparently corre- 
sponded to the innominate, and the other two vessels to the subclavian and common carotid 
of the left side. By these vessels blood was supplied to the head and upper extremities. 
There was no communication between the arterial and pulmonary vessels, as the ductus 
arteriosus was absent. The cause of the dilatation of the beginning of the aorta was a 
thickening and narrowing of the vessel for 8 mm. (J inch) just beyond the dilatation. The 
heart was enlarged, but not especially hypertrophied. 

There was a general streptococcus invasion, for which no cause could be found. The 
cord had come away at the usual time without leaving any abnormal condition in the 
neighborhood of the umbilicus. 

Diagnosis. — Although from what I have just told you concerning the 
symptoms it is usually possible to make a diagnosis of congenital cardiac 
disease, yet when we consider the variety of lesions which may occur, and 
the combination of different lesions which may be present, you will under- 
stand that a diagnosis of the especial lesion is, as a rule, impossible. 

Bearing in mind the mechanism of the foetal circulation (Diagram 1, 
page 19) and the connection which an enlargement of the heart has with 



DISEASES OF THE HEAET. 1027 

especial lesions, we can sometimes arrive at an approximately correct 
diagnosis ; but no reliance can be placed upon the locality or sound of 
the cardiac murmurs, as such murmurs may be produced by very trivial 
lesions, and may be absent where the lesions are most pronounced. 

Peognosis. — Where the lesion is connected with the pulmonary artery, 
and there is an open ventricular septum to act as a safety-valve, the equi- 
librium of the circulation may be retained to such a degree that the child 
will live for a number of years. Where the only malformation is an open 
foramen ovale, life may be prolonged for many years. Where, however, 
other malformations are present, especially of such a grade as to overcome 
the compensatory power of the heart, death generally takes place at an early 
period. Where there is transposition of the main arterial trunks, the infant 
usually lives but a short time. Infants and children with congenital dis- 
ease of the heart are very apt to die suddenly. 

Death ordinarily results from some affection of the lung, sometimes 
from haemoptysis, and it is quite common for tuberculosis to develop in 
these cases of congenital cardiac disease. 

In some rare cases the compensatory power of the heart is so great 
that the equilibrium of the circulation is maintained, and adult life may be 
reached. 

Teeatment. — The treatment of congenital disease of the heart is essen- 
tially hygienic and symptomatic. The infants should be carefully pro- 
tected from atmospheric changes which would be likely to produce bronchial 
irritation, as in many cases bronchitis appears to play an important part in 
interfering with the maintenance of the equilibrium of the circulation and 
in destroying compensation. In a number of cases I have found that the 
administration of digitalis in small doses and with the greatest caution is 
valuable when hypertrophy has begun to fail and dilatation to increase. 
Where the dyspnoea is distressing, a few drops of aromatic spirit of ammonia 
will often give relief. Stimulants are usually indicated. 

Freedom from excitement and over-exertion should be constantly en- 
forced, but the child should be kept in the open air as much as possible. 

Here is another infant (Case 493), three months old, in whom the most striking feature 
of its congenital cardiac disease is extreme wasting. It has a cardiac murmur at the base 
of the heart, and is, as you see, slightly cyanotic. You will notice that the cyanosis some- 
times aflfects the mucous membrane of the mouth, and that the nails are blue. A harsh 
systolic murmur can be detected at the base of the heart. At times the infant has serious 
attacks of dyspnoea and suffocation, but by simply placing it on its right side immediate 
relief is obtained from these symptoms, this procedure evidently bringing into action a 
safety-valve by which some overtaxed portion of the circulatory mechanism is temporarily 
freed from its burden. 

ACQUIRED DISEASES OF THE HEART.— Acquired diseases of 
the heart may be functional or organic, acute or chronic. 

Functional. — Functional affections of the heart do not usually occur 
until the later years of childhood. Functional cardiac disturbances may 



1028 



PEDIATRICS. 



arise from ansemia of the nervous centres and from cardiac irritants, such 
as tea and coffee. They are significant symptoms in the course of such 
neuroses as exophthalmic goitre. 

In these functional cases there are no pathological conditions beyond 
a weakened condition of the muscles of the heart, and possibly, at times, a 
slight degree of dilatation of its cavities. 

The symptoms are palpitation, a weakened irregular pulse, attacks of 
dyspnoea and fainting, and sometimes cardiac murmurs which are seemingly 
hsemic in their nature. 

A marlced example of this class of cases was a boy (Case 494), eight years of age, who 
came under my care with attacks of fainting, palpitation, and dyspnoea. He was taken 
from school and made to play all day in the open air, and in a few weeks these symptoms 
disappeared entirely. 

A considerable quantity of tea is given to some children at as early an 
age as four or five years, and this often leads to functional cardiac disturb- 
ance. A striking example of this class of cases was seen by you at one of 
my previous lectures (page 469, Case 201). 

In these functional cases the subjective symptoms are more apt to be 
marked than where there are organic lesions. 

Organic. — Organic diseases of the heart may be of mechanical or 
of inflammatory origin, and may also be primary or secondary. I have 
arranged this table (Table 1 10) showing the various conditions under which 
organic cardiac disease may arise in early life, and shall ask you to examine 
it before I speak of the various diseases. 







TABLE 


110. 








Mechc 


Acquired Organic Cardiac Disease. 






mical. 


E 


1 
Inflammatory. 


Dilatation. 


Hypertrophy. 


ndocarditis. 


Myocarditis. 


1 
Primary. 

Over-exertion. 
Puberty. 


1 
Secondary. 

Pericardial and 
pleuritic adhe- 
sions. 

Any infiltration of 
lung-tissue. 

Pertussis with its 


Primary. 


Secondary. 
Kheumatism. 
Acute exanthemata 

(scarlet fever). 
Diphtheria. 
Pneumonia. 
Endocarditis recur- 




accompanying 
emphysema and 
atelectasis. 
Increased blood- 






rens (from old 
cardiac malforma- 
tions or lesions). 




pressure, as from 
renal disease or 












narrowing of the 
aorta. 









Organic diseases of the heart are more apt to attack the left side of the 
heart than the right. I shall not dwell in detail on the various physical 



DISEASES OF THE HEART. 1029 

signs of cardiac disease, such as murmurs, thrills, and dulness, as they are 
very similar to those with which you have been made familiar in your study 
of the adult's heart. The importance of recognizing the relative size and 
position of the heart at different ages I have already spoken of in my 
lecture on development (page 122), and I shall therefore refer you to what 
I said on that occasion. There are certain differences, however, between the 
symptoms of cardiac disease in infancy and early life and those in later life. 
In young children murmurs are more apt to be diffuse than in adults, often 
being heard over the entire chest ; and the rate and rhythm of the heart are 
so easily disturbed by nervous influences as to be of little diagnostic value. 
Progressive emaciation is a symptom which is apt to appear speedily. An 
enlarged heart dependent on adhesions from a preceding pericarditis is 
more common in early life than in adults, while compensation, as I have 
already told you, is much more readily acquired. 

I have had. children with cardiac disease presented for treatment at my 
children's cUnic one year with cardiac symptoms so severe that they had to 
be carried ; they were emaciated, and. cyanotic, the area of cardiac dulness 
was increased, and souffles were present; yet these same children would 
return and be shown to the next class of students in the following year, 
walking up-stairs without dyspnoea, looking well nourished, of good color, 
with much less enlargement of the area of cardiac dulness, and with the 
cardiac souffle scarcely perceptible, showing that the cardiac compensation 
was complete. 

As an illustration of this class of cases you will perhaps remember the little girl 
(Case 495) who was brought to the clinic by her mother to be shown as a child who was 
then well, but whose chances of living had seemed at one time very slight. 

When first seen she was about five years old. She had never had any of the acute 
diseases, such as scarlet fever, diphtheria, pertussis, articular rheumatism, or in fact any 
disturbance except slight pains in her limbs. For the previous six months she had lost in 
appetite and weight, got out of breath very easily, suffered from palpitation, and in the 
beginning of her sickness was confined to her bed for a week or ten days with a high fever 
and pain referred to her left side. On examination she was found to be somewhat cyanotic. 
The area of visible cardiac pulsation was much increased. The apex of the heart was in 
the sixth interspace, 3 cm. (1^ inches) to the left of the mammary line. The area of abso- 
lute cardiac dulness extended to the right parasternal line, from the third to the fifth carti- 
lage, and 1 cm. (| inch) to the left of the mammary line on a level with the left nipple ; 
the vertical area of dulness to the left of the sternum extended from the second to the sixth 
interspace. There was a loud mitral systolic murmur. The lungs were normal. 

The chief points of treatment in this case were the careful administration of nourishing 
food and the enforcement of rest. She was always carried up and down stairs for almost a 
year. She grew worse for a time ; she became irritable, and for some time when the 
cyanosis and orthopnoea were most marked she had a cough, and once or twice hremoptysis. 
By the following winter, however, the general symptoms were much improved, and in 
another year the dyspnoea, cyanosis, palpitation, and pain had passed away. The apex of 
the heart was found to be in the fifth interspace in the mammary line, and the area of 
dulness very little greater than normal. 

Cardiac symptoms dependent on organic lesions may arise, and yet no 
physical signs of such lesions be detected during lile. 



1030 PEDIATRIC5S. 

Mechanical. — The mechanical conditions in cardiac disease play a very 
interesting and important part in many diseases in infancy and early child- 
hood, and by their results often interfere seriously with the general physical 
condition and normal development of the child. These abnormal condi- 
tions may result in hypertrophy or dilatation from over-exertion ; they may 
occur at puberty ; they may arise from direct mechanical interference with 
the heart's action, as from adhesions or from undue pressure on the cardiac 
cavities, as in pulmonary disease, pertussis, renal disease, and narrowing 
of the aorta. In all these diseases there is a greater liability that acute 
dilatation may take place in early life than that it may occur at a later 
period. You should therefore always remember to examine the heart 
carefully during the course of all these diseases. The processes which 
suddenly cause great increase of the blood-pressure in the lungs may lead 
to acute dilatation of the right ventricle, while where there is a diffuse 
renal disease, as in scarlet fever, acute dilatation of the left ventricle may 
take place, and be followed by hypertrophy, as I have explained to you in 
my lecture on scarlet fever (page 569, Case 245). In all these diseases this 
acute dilatation may take place rapidly and disappear almost as rapidly, 
a phenomenon which is somewhat characteristic of cardiac disease in early 
life. 

I have already referred to the great changes which take place in the 
heart, and to its rapid growth, at the time of puberty. At this period the 
general growth of the child is apt to be very rapid, and symptoms of car- 
diac weakness commonly occur, especially in girls. These symptoms are 
debility, lack of energy, palpitation, and dyspnoea on exertion. There may 
also be signs of slight cardiac dilatation, and murmurs, probably hsemic 
in their nature. This period, therefore, is one in which cardiac disease from 
any cause, such as rheumatism, is of more serious import than at a later 
period, when the heart is not taxed by too rapid growth. 

These cases should be treated by mild physical exercise, care being taken 
that the children do not over-exert themselves. Complete rest for two 
or three hours every day should be enforced. Under this treatment, com- 
bined with nutritious food and possibly a tonic of iron or nux vomica, the 
signs of cardiac disturbance usually soon disappear. 

I must again remind you of the importance of mechanical interference 
with the action of the heart arising from adhesions. Adhesions of the peri- 
cardium or in its neighborhood are so latent in infancy in their symptoms 
that they are often overlooked until the mechanism of the heart has become 
so seriously interfered with as to present the symptoms of disease of the 
heart itself, such as dilatation or hypertrophy. 

Inflammatory. — The chief inflammatory lesions of the heart are endo- 
carditis and myocarditis. 

Endocarditis. — The most common cardiac disease which occurs in chil- 
dren is endocarditis. Endocarditis may be acute or chronic, primary or 
secondary. 



DISEASES OF THE HEART. 1031 

Etiology. — The elaborate investigations of J. H. Wright, W. R. 
Stokes, and others have shown that acute endocarditis is of bacterial origin. 
Weichselbaum has contributed more to our knowledge of this disease than 
any other investigator. He has proved that there is no essential difference 
between the various forms of endocarditis, either histologically or patho- 
logically, and that no one species of bacteria is exclusively concerned in the 
production of the disease. Sometimes the streptococcus pyogenes is found, 
sometimes the staphylococcus pyogenes aureus, and sometimes the diplococcus 
pneumoniae. We therefore no longer need make a distinction between simple 
endocarditis and ulcerative or verrucose endocarditis. There is merely a 
difference in the degree of the malignant nature of the especial organism 
which has produced the disease, or in the vulnerability to infection of the 
individual. 

Pathology. — While the same lesions of endocarditis may be found in 
children as in adults, yet in infancy, although marked acute cardiac symp- 
toms and murmurs frequently arise, the autopsy almost invariably fails to 
show any endocardial lesions or growths. In two thousand autopsies at the 
New York Foundling Asylum, Dr. Northrup and Dr. O'Dwyer never 
found an acute inflammatory lesion except in one case, which showed the 
lesions of acute malignant endocarditis. Where the lesions of endocarditis 
are found in children, the connective tissue and the basement substance are, 
according to Del afield and Prudden, principally concerned in the inflam- 
matory process. The endocardium which forms the valves is that which is 
most frequently inflamed, but other portions of it are by no means exempt, 
In some cases there is swelling of the valves, which are thickened, their 
surfaces remaining smooth, the basement substance is swollen, and there is 
a moderate production of new connective-tissue cells. In other cases the 
growth of connective-tissue cells is very much more marked, the basement 
substance is broken up, and little cellular fungus-masses, called vegetations, 
project from the free surface of the endocardium. In still other cases the 
cellular growth in some places forms vegetations, and in others degenerates, 
and thus portions of the valves are destroyed. This is simple acute ulcer- 
ative endocarditis. 

In some cases the children recover, and the valves seem to return to 
their normal condition, while in others the valves are left permanently 
damaged. 

Chronic endocarditis may succeed an acute endocarditis, or the inflamma- 
tion may be chronic from the onset. It affects most frequently the aortic 
and mitral valves and the endocardium of the left auricle and left ventricle, 
similar changes in the right side of the heart being much less frequent. In 
these cases the endocardium may be thickened and tense, and its surfaces 
smooth or covered with small, hard vegetations or ridges, or there may be a 
growth of connective-tissue cells in the endocardium, with a splitting up of 
the basement substance. 

While endocarditis may be primary, simply arising from the infection 



1032 PEDIATRICS. 

of some organism^ it is commonly secoudaiy. It arises most frequently in 
connection with rheumatism and chorea, also in the course of the acute 
exanthemata, especially scarlet fever, and in diphtheria. Acute endocarditis 
may also be secondary to old cardiac malformations or lesions {endocarditis 
recurrens). 

In connection with endocarditis myocarditis may be present. In this 
event there is an inflammatory change in the walls of the heart, involving 
primarily the interstitial tissue and blood-vessels, the muscular fibres being 
secondarily affected by atrophic and degenerative changes. 

Symptoms. — The symptoms of endocarditis are often obscure, and in 
infants and young children, in the beginning, are apt to be latent. When 
the disease arises in connection with some other disease, such as rheuma- 
tism, the symptoms are especially likely to be masked by those of the 
disease which it complicates. In some cases the endocarditis develops in- 
sidiously without any additional symptoms, and its presence is not recog- 
nized until a careful examination of the heart detects a murmur ; in others 
pronounced and even violent cardiac symptoms are present from the be- 
ginning. If the muscular tissue is involved as well as the endocardium, 
the general cardiac symptoms of dyspnoea, cyanosis, and palpitation are still 
more marked. 

The symptoms of myocarditis, however, are so closely associated with 
those of an accompanying endocarditis or pericarditis that clinically, as a 
rule, they cannot be separated from them. 

Where endocarditis does not arise as a complication of some other dis- 
ease, the symptoms at the onset, when prominent, are usually a rise of tem- 
perature, a quickened and sometimes weak and irregular pulse, dyspnoea, 
palpitation, and more or less prsecordial distress. All these symptoms vary 
according to the extent of the lesions. Later they depend upon whether or 
not compensation has been established. In connection with these early 
symptoms, cardiac dilatation and cyanosis are very apt to occur. When 
the disease has advanced far enough to cripple the heart and to interfere 
with compensation, the physical signs of enlargement appear, such as in- 
crease in the area of cardiac dulness and the presence of murmurs corre- 
sponding to the orifices affected. The symptoms differ somewhat according 
as the inflammatory condition has begun in the valves or in the cardiac 
walls. (Steffen.) In the former case the signs of dilatation accompany 
those of valvular weakness, while in the latter the symptoms of dilatation 
come first, and are followed by the mechanical results of valvular insuf- 
ficiency. 

In a first attack of acute endocarditis such serious symptoms connected 
with great lack of compensation as are met with where the attack supervenes 
on a previous cardiac lesion are not likely to arise. In some cases, how- 
ever, where the individual power of cardiac resistance is slight, these ad- 
vanced symptoms appear. Under these circumstances the child emaciates 
rapidly, becomes very weak and anaemic, and the cyanosis and dyspnoea. 



DISEASES OF THE HEART. 1033 

the latter of which may amount to orthopnoea, increase. There is apt to be 
cough from an accompanying bronchial irritation, produced most frequently 
where there is obstruction at the mitral orifice, and, following a general 
venous stasis, enlargement of the liver, haemoptysis, and oedema of the face, 
legs, and arms appear. Children show such a wonderful recuperative power 
that even in these advanced cases under proper treatment the serious symp- 
toms may gradually pass away, and often such complete cardiac compensa- 
tion takes place that they are left with no symptoms of cardiac disease 
except a murmur. 

In endocarditis relapses are common and there is a great tendency to 
recurrence. Embolism may take place, and sometimes the first symptom of 
cardiac disease which has been noticed is a hemiplegia following a lesion 
of the mitral valve. Anaemia is a very common symptom, especially where 
endocarditis accompanies rheumatism. Congestion of the lungs, with result- 
ing haemoptysis, may arise where there is insufficiency of the mitral valve. 
Although when the valves are affected murmurs are usually present, yet 
sometimes where there are lesions of the valves murmurs cannot be detected. 
In endocarditis murmurs are most frequently heard in the region of the 
mitral valve, and insufficiency of the mitral valve is the most common of 
the inflammatory cardiac lesions in childhood. 

Diagnosis. — The diagnosis of endocarditis depends upon the physical 
signs. These signs are an increase in the area of cardiac dulness and a 
change in the cardiac sounds. The change in the area of cardiac dulness 
must be differentiated from that which occurs in a pericardial effusion, of 
which I shall speak later (page 1056). 

The change in the cardiac sounds may be produced by changes in the 
blood or by organic lesions of the valves. The differential diagnosis between 
these two conditions is the same as in adults, and therefore I shall not dwell 
upon it. In insufficiency of the mitral valve the murmur is systolic, and is 
transmitted to the axilla and the back. In some cases the murmur of mitral 
insufficiency is closely simulated by a valvular sound produced in the course 
of pericarditis. Stenosis of the mitral valve is much less common than 
insufficiency. It is represented by a presystolic murmur heard in a limited 
area in the region of the heart's apex, and is sometimes accompanied by a 
reduplication of the cardiac sounds at the apex and by a thrill. Pain is 
said to be more common in connection with this lesion than with other 
cardiac defects. Lesions of the aortic valve are almost invariably associated 
with rheumatism. Stenosis of the aortic orifice is very apt to be associated 
with a mitral lesion. There is nothing especially characteristic in childhood 
of these lesions of the aortic valves, and the same may be said of lesions of 
the tricuspid valves. 

Where endocarditis has become chronic and compensation has only 
partially taken place, the children are atrophic, anaemic, and have a ten- 
dency to imperfect circulation and to bronchitis. In some cases the fingers 
become club-shaped. 



1034 PEDIATRICS. 

Prognosis. — The prognosis of acquired endocarditis in early life is 
very favorable. I have already referred to the great recuperative powers 
of the child, and in many cases, especially where it is the first attack, such 
complete compensation takes place that the child practically recovers. If it 
is the walls of the heart that are affected, the heart may regain its normal 
size and position. If the valves alone, or the valves and the walls, are 
affected, reaction can still take place. Death may, however, occur at the 
height of the attack, or the child may die later from exhaustion and some- 
times suddenly from heart-failure. 

Treatment. — The treatment of acute endocarditis during the early 
days of the attack is essentially rest in bed, and is otherwise symptomatic. 
From the very beginning, however, we must bear in mind that our treat- 
ment should be directed to establishing compensation. We should also 
remember that the younger the child the more likely it is that we shall 
have to contend with a resulting atrophic condition and anaemia. The child 
should be encouraged to sleep, in order that the circulation may be kept 
as quiet as possible and thus relieve the work of the disabled heart. The 
heart-beats of a young child during sleep are often reduced twenty in a 
minute, and thus sleep affords the best opportunity for compensation. The 
treatment which I have found most efficient in all forms of cardiac disease 
is absolute rest in bed for days or even weeks until compensation has become 
complete. Later the general health of the child should be carefully attended 
to by means of good food, pure air, and exercise of a mild type, never ex- 
cessive. The surface circulation should be promoted by baths and gentle 
massage. Digitalis and iron are of great value, the former in aiding the 
establishment of compensation, the latter in combating the anaemia. If at 
any time during the course of the disease the attacks of dyspnoea are exces- 
sive, nitroglycerin can be given in doses proportionate to the age of the 
child ; 0.0003 gramme (g-J-Q grain) can be given to a child three or four years 
old. 

Although the more advanced pathological condition usually spoken of 
as '^ulcerative endocarditis'^ rarely occurs in young children, yet it is at 
times met with. Its symptoms are obscure, and the diagnosis is rarely 
made during life. 

I have here the organs of a child who has lately died in my wards with 
this disease. 

This boy (Case 496), four years old, was attacked one montli ago with fever, thirst, 
and pain in his knees. Later his feet became painful and swollen, and other joints were 
successively involved. He complained of pain in the back of his neck and along his spine. 
One week before entering the hospital he began to have moderate but incessant choreic 
movements, and he showed much incoordination of mastication and articulation. 

A physical examination showed the lungs to be normal, the area of cardiac dulness 
somewhat increased to the left of the mammary line, and a murmur at the apex, with the 
first sound transmitted to the axilla and the back. On the following day a pericardial fric- 
tion-sound was heard just above the left nipple, accompanied by precordial pain. Two 
weeks later the choreic symptoms disappeared, and the temperature became normal. The 



DISEASES OF THE HEART. 1035 

area of cardiac dulness did not extend under the sternum, but was found to correspond 
to the impulse of the heart, which was 1.4 cm. (^ inch) outside of the left mammary line. 
During the last week of its life the child became very weak, had marked dyspnoea, and 
showed signs of effusion in the right pleural cavity, but presented no other symptoms. It 
died yesterday. 

The post-mortem examination was made by Dr. Councilman. 

Both pleural cavities contained a considerable accumulation of blood-stained fluid. 
The anterior mediastinum was deeply injected and reddened, and the mediastinal lymph- 
glands beneath the sternum were enlarged. The apex of the pericardium was tightly 
adherent to the left pleura, and about this point the tissues were thickened, deeply injected, 
and cedematous. The right lung was adherent to the pleura by comparatively fresh adhe- 
sions. Here and there over the pleural surface of the lung is a slight fibrinous exudation. 
The lymphatics over the surface of the pleura are greatly dilated. The upper lobe of the 
right lung is congested. :Small nodular masses can be found beneath the pleura, and on 
section, as you see, there is a distinct lobular consolidation throughout the upper lobe of 
the right lung. The solid portion of the lung is of a dark-red color and comparatively 
smooth on section. Muco-purulent matter can be squeezed from the larger bronchi. The 
small consolidated areas are more or less separated from one another, and between them 
are cavities in the interlobular septa. The appearance of the lung is somewhat similar to 
that presented in bovine pleuro-pneumonia. The bronchial glands are enlarged and 
reddened. The left lung was not so adherent as the right. All over the posterior portion 
of the pleura there was a slight fibrinous exudation. This lung has been somewhat com- 
pressed by the accumulation of fluid in the pleural cavity, but otherwise shows about the 
same condition as the right lung, the consolidation being in the posterior portions princi- 
pally. The pleural cavity, as you see, is obliterated by the adhesions. The parietal peri- 
cardium is greatly thickened, and in and between the connective-tissue adhesions there is 
a thick fibrinous exudation. The heart is somewhat enlarged. At the apex of the left 
ventricle, at a point corresponding to the adhesions of the pericardium, the myocardium 
feels soft and is somewhat whiter than the remainder of the tissue. The interior of the 
right heart contains tolerably firm, fresh clots. The myocardium of the right side of the 
heart is pale and soft. Along the free border of the right auriculo-ventricular valve there 
are a few fresh vegetations. The left side of the heart is dilated. The edge of the mitral 
valve is thickened and eroded. There appears to be a slight loss of substance in the thick- 
ened portion of the valve, and the edges are irregular and eroded. The muscular substance 
of the heart is generally pale. Beneath the endocardium there are small, whitish points. 
Similar points are seen on the papillary muscles and on the inner side of the auricle. The 
aortic valves are intact, except for a few fibrinous deposits just at the edges of contact. 
The coronary arteries are normal. 

The spleen is enlarged and comparatively soft. The mesenteric lymph-glands are 
enlarged and also slightly soft. The liver is large, dark red in color, and the lobules are 
prominent. 

The left jugular vein is filled by a firm, adherent thrombus, which extends downward 
into the subclavian vein, the innominate, and the superior vena cava, and completely ob- 
literates those veins. 

A microscopic examination of the lungs shows a distinct lobular pneumonia. The 
alveoli contain very little fibrin, but are filled with large, pale cells. Among these are a 
few leucocytes, but usually the leucocytes are conspicuously absent. The consolidation 
is quite general, comparatively few of the alveoli in the most affected portions being free. 
At numerous places in the lung there are wide passages, apparently lymphatics, filled with 
fibrin and large, pale cells similar to those in the alveoli. The bronchi are in most cases free. 
The lung consolidation does not appear to take its point of departure from the bronchi. 

Typical masses of streptococci are found in the alveolar contents and in their walls. 
The lymphatics of the pleura are enlarged, and correspond to the large passages just 
described in the lung. Sections of the bronchial and cervical lymph-glands show acute 
swelling of the glands, with micrococci here and there in the sinuses. 

A microscopic examination of the heart showed the vegetations on the mitral valve to 



1036 



PEDIATRICS. 



be distinctly verrucose. Here and there on the ends of these vegetations were small masses 
of fibrin. Only in places was there a direct infiltration with leucocytes. Streptococci were 
found on the edges of the vegetations, chiefly in the fibrin. In but one place were they 
found within the tissue. Sections of the myocardium embracing the pericardium showed a 
fibrino-purulent exudation on the pericardial surface. Numbers of streptococci were found 
in the fibrinous exudation and in a few places on the edge of the cardiac muscle. Sections 
from the left ventricle showed a marked adhesion with the pleura and an acute inflamma- 
tion with a few streptococci in the tissue. The thrombi in the large cavity showed no 
evidence of organization, and no streptococci were found in them, but there were numbers 
of them in the perivascular tissue, which showed slight purulent infiltration. 

Sections of the liver, kidney, and spleen showed no pathological condition save a 
slight, cloudy swelling, and no organisms were found in these tissues. 

Cultures made at the autopsy gave a pure culture of streptococci from the lungs, from 
the pericardium, and from the bronchial lymph -glands. In the spleen only a few colonies 
were found. The other organs were sterile. 



Case 497. 




Acute endocarditis. Mitral insufficiency. Male, 83^ years old. 



As Dr. Councilman says, the most interesting part of the autopsy Is the manner of 
infection. He thinks that the heart must have become infected before the lungs, so that 
apparently this is a case of primary endocarditis of the malignant form. It seems very 
probable to Dr. Councilman that the path of the infection was from the heart to the peri- 
cardium, thence to the mediastinum, producing the thrombus of the veins, and probably 
thence to the lung, possibly by means of the thrombosed veins. The thrombi seem to 
have been due to an inflammation of the wall of the vein, produced by the streptococci in 
the perivascular tissue. From this point they could have got into the veins, the infec- 
tion being carried thence into the lungs. The pneumonia in the lungs is entirely dif- 
ferent from the ordinary broncho-pneumonia of infants, which is due to aspiration, and in 
which the chief seat of the disease is in the bronchi and the surrounding lung-tissue. In 
this case, however, the bronchi are less involved than other portions of the lung. 



I have here in the wards a number of cases which illustrate the various 
types of cardiac disease. 



DISEASES OF THE HEAET. 



1037 



This boy (Case 497, page 1036), eight and a half years old, was well until nine weeks 
ago. He had never had any diseases, except measles and varicella when he was four years 
old. Nine weeks ago he was attacked with chorea, which lasted for about seven weeks 
and was succeeded by symptoms of dyspnoea on exertion, loss of appetite, and slight cough. 
There has been no history of rheumatism in the case. You see that he is cyanotic, but 
otherwise looks comparatively well. 

There is no oedema, and an examination of the lungs detects nothing abnormal. The 
impulse of the heart is in the left mammary line in the fifth interspace. The cardiac area 
of absolute dulness is as I have indicated with this black curved line. I have also marked 
the lower border of the ribs with a plain black line, and have shown the slightly enlarged 
liver aiid spleen with a broken line. The dulness does not extend beyond the middle of 
the sternum, but is increased in the vertical line as high as the second interspace and 
extends slightly beyond the left mammary line. There is a marked systolic murmur, heard 
most loudly at the apex, and transmitted to the axilla and the back, also to the base of the 
heart. 

This appears to be a case of acute endocarditis arising during an attack of chorea. The 
prognosis is good, as the child is already improving. 

(Subsequent history.) The child was treated simply by rest in bed, and a month later 
his general symptoms improved, Ihe areas of splenic, hepatic, and cardiac dulness were 
much decreased, and the cardiac murmur was not so distinct. Two weeks later compensa- 
tion was apparently established, he had gained in weight, his color became better, and he 
left the hospital in good condition. 

CHAKT 45. (Case 498.) 





Days of Disease. 




F. 






















c 


407° 
106° 
105° 
104 
103 
102 
101 
100° 
99 

NORMAL 

TEMP-o 

98 

97° 
96 
95° 


ME 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


ME 


41.6° 
41.1° 
40.5° 
40.0° 

39.4° 

38.8° 

38.3° 

37.7° 

37.2° 
37.0° 
36.6° 

36.1° 

35.5° 

35 0° 












































































































y 


















\ 




^ 






















/ 


A 










/ 








/ 


/ 


/ 






y 


/ 


















/ 


















^^ 











































Acute endocarditis. Female, 9 years old. 



I have here a girl (Case 498, I., page 1038), nine years old, who, although she has 
always been a delicate child, never had any especial disease until two weeks ago, when she 
was attacked with fever, palpitation, cough, and a rapid, irregular pulse. On entering the 
hospital she was cyanotic, the face and extremities were cold, and there was considerable 
prominence over the cardiac region. The resonance of the lungs was normal, but there 
were a few moist rales at both bases. The impulse of the heart was in the fifth left inter- 
space, 1.4 cm. (J inch) outside of the mammary line, and there was a marked thrill with 
a systolic murmur transmitted to the axilla and heard distinctly in the back. The liver 
was slightly enlarged. Here is the temperature chart (Chart 45), showing the temperature 
■during the acute inflammatory stage of the endocarditis. 



1038 



PEDIATRICS. 



The impulse of the heart is scarcely perceptible. The area of cardiac dulness extends, 
as you see, to the right edge of the sternum, and slightly beyond the right parasternal line 
beneath the third intercostal space. 




Acute eu<ln(;ar<li 



.Mitral insulliciency. Luck of compensati(jn. Orthopnoea. Female, <) years old. 



The case illustrates an attack of acute apparently primary endocarditis. The acute 
inflammatory stage has been passed ; dilatation has taken place, and there is at jiresent 
marked failure of compensation. This is shown by the feeble impulse of the heart, the 
weak and fluttering pulse, the cold and blue extremities, the orthopnoea, and the tendency 
to oedema of the face, legs, and feet. You see the position which the child assumes on her 
right side, how she supports herself with her arms, and her anxious expression as she en- 
deavors to keep herself in a position in which she can breathe easily. 




Acute endocarditis. Dilated heart. 



Orthopnoea. Position assumed when sleeping. Female, 
y years old. 



A case of this kind needs to be very closely watched, as the child is liable to die sud- 
denly. A few days ago, in this next bed, there was a boy (Case 499), four and a half 
years old, who was sufl'ering from an attack of acute endocarditis : he had the same symp- 



DISEASES OF THE HEART. 



1039 



toms of dilated heart witli a lack of compensation as you see in this little girl. While 
he was sleeping in the same position which she has assumed since I have been describing 
her case to you (Case 498, II., page 1038), he died suddenly. He had been subject to 
sudden violent attacks of dyspncea, and once or twice while in the hospital had an attack 
of angina pectoris. 

This next child (Case 500), a girl, thirteen years old, has a history of pertussis some 
years ago, but has not had any other disease except an attack of rheumatism two years ago. 
Since then she has occasionally had attacks of dyspnoea when at play and when going up- 
stairs. She has also at times had oedema of the feet. One week ago she complained of pain 
in the cardiac region, so severe as to interfere with her sleep. On entering the hospital she 
had a temperature of 38.5° C. (101.2° F.), a pulse of 104, and respirations 65. An exami- 
nation showed nothing abnormal except in the cardiac region. 

Case 500. 




Chronic endocarditis following rheumatism. Mitral stenosis and insufficiency. Anismia. Female, 

13 years old. 



The impulse of the heart is in the fifth left interspace in the mammary line. The area 
of absolute cardiac dulness is enlarged, and I have represented it by a black curved line. 
You see that it extends beneath the sternum, and at the junction of the upper border of 
the fourth rib extends a short distance to the right of the sternum. The upper boundary, 
as I have said, is the upper border of the third rib, and is about 5.3 cm. (2 inches) outside of 
the mammary line. There is a presystolic murmur at the apex, which is confined to a limited 
area. There is also a systolic murmur at the apex transmitted to the axilla and the back ; 
the pulmonic second sound is accentuated. 

(Subsequent history.) Four weeks later, after being treated by complete rest in bed, 
the cardiac symptoms almost entirely disappeared, the area of cardiac dulness was much 
diminished, and the murmurs were less distinct. Two weeks later the child left the hos- 
pital, much improved m her general health, but in a very anaemic condition. 



1040 PEDIATRICS. 

This next boy (Case 601), nine years old, had an attack of rheumatism when he was 
six years old. 

Case 501. 




Chronic endocarditis following rheumatism. Mitral insufficiency. Pericarditis sicca. Dilated heart. 
Pneumonia. Pleurisy. Male, 9 years old. 

Four weeks before entering the hospital he began to have swelling of the feet, and four 
days before entrance swelling and pain in the cardiac region and much dyspnoea and general 
discomfort. His respirations and pulse were much quickened, and his temperature was 
raised. On entering the hospital, a physical examination showed that he had pneumonia of 
the left lung. A pericardial friction-sound was also heard in the second left interspace. 
The cardiac area of absolute dulness extended as far as the right parasternal line, as high as 
the third rib, and 5.3 cm. (2 inches) beyond the left mammary line. There was a soft systolic 
murmur at the apex. The pneumonia involved the whole of the left lung, and was com- 
plicated by a moderate pleuritic eftusion. Resolution took place, however, and the fluid was 
absorbed. The cardiac symptoms improved as soon as the pneumonia and pleurisy disap- 
peared, but the physical signs of the dilated heart have not yet changed. For some weeks 
I shall enforce absolute rest in bed, as this morning he was suddenly attacked with extreme 
dyspnoea, cyanosis, and collapse, which followed his getting out of bed and dressing himself 
contrary to my directions. 

I have indicated the area of absolute cardiac dulness in black, which shows an enlarged 
heart, as you will understand better when I describe the dulness produced by a pericardial 
effusion. There is no visible impulse of the heart, and the beat can scarcely be found on 
palpation. The increased area of dulness is therefore practically caused by dilatation rather 
than by hypertrophy, and this supposition is substantiated by the symptoms of lack of com- 
pensation which he has shown. 

This boy (Case 502, page 1041), eleven years old, had measles when he was an infant, 
diphtheria when he was three years old, and pertussis when he was four years old. He had 
always been well until one and a half years ago, when, after indefinite pains in his joints, 
accompanied by no swelling and not sufliciently severe to confine him to bed, he began to 
have dyspnoea on exertion, and cardiac pain. He is somewhat cyanotic, and has lately lost 
a great deal in weight. There is no oedema, and nothing else abnormal is detected except in 
the examination of the heart, which shows the area of absolute dulness to be somewhat in- 
creased. A loud presystolic murmur is heard at the apex, limited in its extent and accom- 



DISEASES OF THE HEAKT. 1041 

panied by a thrill. He has also had a cough. He seems to represent a case of stenosis 
of the mitral valve. There is, as you see, decided enlargement in the cardiac region to the 
left of the sternum. 

(Subsequent history.) After remainmg in the hospital for two months and being 

treated by rest, compensation was established, and he left the hospital in good condition. 

Case 502. 




Chronic endocarditis. Mitral stenosis. Bulging of left side of sternum. Male, 11 years old. 

Since then he has returned from time to time with a renewal of the symptoms of cyanosis, 
dyspnoea, and lack of compensation. 

This next boy (Case 503, I., page 1042), ten years old, is interesting as illustrating cer- 
tain characteristics of cardiac disease in early life. 

Two years ago he entered the hospital with marked cedema of the face, body, and limbs, 
ascites, a slight amount of fluid in both pleural cavities, and oedema of the lungs. There 
was no definite history of rheumatism nor any other cause for the cardiac disease which was 
causing these symptoms, and which had apparently developed insidiously, though if he had 
been under closer observation a definite period of onset would probably have been discovered. 
The impulse of the heart was found to be 1.4 cm. {^ inch) outside of the mammary line 
in the fifth left interspace. The area of cardiac dulness was somewhat increased. There 
was a loud systolic murmur at the cardiac apex transmitted to the axilla. The second 
pulmonic sound was much accentuated. Here is a picture (Case 503, II., facing page 1042) 
taken at that time, and showing the marked oedema of the legs and the much distended 
abdomen. He was treated by complete rest in bed for five weeks, and in the beginning 
digitalis was administered until the urine, which was lessened in quantity, had increased 
and the oedema of the lungs had disappeared. On entering the hospital the ascites was 
removed by paracentesis abdominis. Under this treatment the child rapidly improved, 
the general oedema disappeared, the liver returned to its normal size, the area of cardiac 
dulness was markedly decreased, the cardiac murmur became less marked, and six weeks 
from the time when he entered the hospital complete compensation was established and he 
left the hospital seemingly perfectly well. This picture (Case 503, III., facing page 1042), 

66 



1042 



PEDIATRICS. 



was taken just before he left the hospital, and, as you see, is in marked contrast to the 
picture taken on his entrance. 

Case 503. 
T. 




Chronic recurrent endocarditis. Mitralinsufficiency. Disturbance of compensation. Dilated heart. 
Enlarged liver. (Edema of lungs. Ascites. Male, 10 years old. 



Since leaving the hospital the hoy is reported to have been very well, except that he 
could not play or work hard. Two weeks ago he was attacked with fever, prsecordial dis- 
tress, and cardiac pain; later he began to have oedema of the feet and dyspnoea. Since 
then he has heen growing progressively worse, and his case illustrates a fresh attack of en- 
docarditis supervening on an old chronic endocarditis (endocarditis recurrens) and resulting 
in a disturbance of the previous compensation. You see that he has orthopnoea to such an 
extent that he is unahle to lie down in bed, and that he has to he continually watched hy a 
nurse, as he frequently has attacks of excessive paroxysmal dyspnoea which are liahle to 
prove fatal. There are cyanosis of the lips and hands and marked general oedema. The 
skin of the nose and extremities is cold. The impulse of the heart is felt in the sixth left 
interspace 2.8 cm. (1 inch) heyond the mammary line. The area of cardiac dulness ex- 
tends heneath the sternum, and at the third intercostal space extends 1.4 cm. (J inch) to 
the right of the sternum, thence upward in a curved line across the upper part of the ster- 
num to the second rib, and then, keeping outside of the mammary line, descends and joins 
the point of cardiac impulse. There is a loud systolic murmur, heard most distinctly at the 
apex, but transmitted over the whole cardiac area and through the axilla to the back. The 
second pulmonic sound is accentuated. The aortic sounds are weak. There are numerous 
moist rales heard in all parts of the lungs. The percussion of the lungs is resonant every- 
where except in the lower parts, where there seems to be a slight amount of fluid in both 




Chronic eiidocanlitis. Mitral iiiMitiicieucy. General Ltilema and ascites. (Before treatment.; 



Case 503. 
III. 




Chronic endocarditis. Complete compensation. (Six weeks after treatment.) Male. 10 years old. 



DISEASES OF THE HEAET. 



1043 



pleural cavities. The liver is enlarged so that it extends 7.8 cm. (3 inches) below the margin 
of the ribs. Ascites is present, the fluid rising to about the line of the umbilicus. The 
spleen is normal in size. The child is passing only a small amount of urine, which contains 
a trace of albumin. I have marked the cardiac and hepatic areas of dulness and the upper 
border of the ascites by black lines, the margin of the ribs by broken lines, the point of 
cardiac impulse by a black ring, and the cedematous rales in the chest by smaller black 
rings. The prognosis in this case, although from the child's present condition very serious, 
as he is liable to die suddenly at any time if extra blood-pressure should be brought to bear 
upon the dilated and crippled heart, is not entirely unfavorable, as he has previously shown 
such great powers of compensation and recuperation. As there is no great distention of the 
abdomen, I shall not at present remove the ascites by paracentesis, but shall have the child 
carefully watched, and, if the ascites increases, shall have it removed at once. He is taking 
infusion of digitalis, 3.75 c.c. (1 drachm), every three hours, and diuretin, 0.36 gramme (6 
grains), once in six hours as a diuretic. His diet is milk. 

(Subsequent history.) Within forty-eight hours rapid relief was obtained from the 
urgent symptoms, and at the end of three weeks the oedema of the lungs, the general 
oedema, and the ascites had disappeared entirely. The urine became normal in quantity and 
free from albumin. One week later he was well enough to be out of bed for an hour each 
day, and at that time this picture was taken (Case 508, IV.), which shows the heart and 
liver to be still enlarged. 

Case 503. 
IV. V. 





Chronic endocarditis, Mitral instifl&ciency. 
Eetuming compensation. Enlarged liver. En- 
larged heart. 



Chronic endocarditis. Mitral ill^ufliciency. 
Broken line indicates enlarged heart. Black line 
indicates area of cardiac dulness with retimisd 
and complete compensation. 



Some weeks later the liver regained its normal size, and still later the cardiac area of 
dulness was found to be much reduced and in the vertical line almost normal. This picture 
(Case 503, V.) shows the enlarged heart, which remained longer than the enlarged liver, 



1044 



PEDIATRICS. 



and is represented by a broken line ; tbe area of dulness of the heart as it appeared when 
he left the hospital is shown by a black curved line. 

This next case, a girl (Case 504), nine years old, is instructive as showing the difference 
between the cardiac area of dulness produced by an enlarged heart and that produced by a 
distended pericardium. She had pertussis when she was three years old, and measles when 
she was seven years old. This was followed by an attack of rheumatic fever, which lasted 
six weeks. So far as I can ascertain, she had no cardiac disturbance at that time, and 
recovered completely from the attack of rheumatism. Two months later she had another 
attack of rheumatism, which was accompanied by pain in the cardiac region. She then 
apparently recovered, but one year later had a recurrence of the cardiac disturbance, which 
was, however, of short duration. From that time she remained well until four months 
ago, when she had a severe attack of bronchitis, and since then she has been failing in 
strength and has suffered from dyspnoea. Three weeks ago she began to have oedema of 
the feet and of the abdomen, and this has been progressively increasing. She is very 
anaemic, and, as you see (Case 504, I., facing page 1044), the oedema of the face and legs is 
marked. The distention of the abdomen is found to be produced by ascites. An examina- 
tion of the heart shows the apex-beat to be in the sixth interspace, 4 cm. (IJ inches) be- 
yond the mammary line. The area of absolute dulness extends from the third left costal 
cartilage downward across the sternum to 2.8 cm. (1 inch) beyond the right parasternal 
line in the fifth interspace. It also extends to the left and downward outside the mammary 
line until it joins the impulse of the heart in the sixth interspace. This area of dulness is 
not that which we meet with in a dilated heart alone, as I shall presently explain to you. 
On the contrary, it suggests that there is fluid in the pericardium. 

In connection with the general oedema and absence of symptoms of pericarditis there 
is probably present the condition called hydropericardium. The liver is also enlarged. The 
pulse is regular, 140. There is a systolic murmur at the apex of the heart. 

She is being treated by absolute rest in bed, a milk diet, infusion of digitalis, and 
diuretin. 

(Subsequent history.) After she had been in the hospital for forty-eight hours the 
hydropericardium disappeared, the skin became less tense, the urine increased in amount, 

Case 505. 




Chronic endocarditis. Greatly dilated heart. General oedema. Extreme distention of abdomen with 

ascites. Female, 11 years old. 



and there was rapid improvement in all the general symptoms. Two weeks later the oedema 
and ascites disappeared entirely, as is shown in a picture (Case 504, II., facing page 1044) 
taken at that time. The enlarged heart at that time is indicated by a broken line, while 



Case 504. 
I. 




X ^m d 



iidocjinlitis. Mitnil iii^uirKMi'iicy. Hydropcrirardiinn, < iriiiTal MMlcina ami a-cii.'- Tlieline 
of ascites and of tlie cardiac area of dulnei^s marked in black. (Before treatment.) 



Case 504. 




Chronic endocarditis. Enlarged heart. Emaciation. (Two weeks after treatment. ) l\-LUciic. J years old. 



DISEASES OF THE HEART. 



1045 



the area of dulness, which was found some weeks later when compensation was established, 
is represented by a black line. The child was left in a very anaemic and emaciated condi- 
tion, but the liver resumed its normal size, the area of cardiac dulness gradually became 
smaller, compensation was finally established, and she left the hospital in good condition. 

Here is a girl (Case 505, page 1044), eleven years old, who has just been admitted to 
the hospital. 

She shows, as you see, extreme dyspnoea, orthopncea, cyanosis, marked general oedema, 
and great distention of the abdomen produced by ascites. Percussion of the chest shows 
extreme dilatation of the heart over an area which includes the entire sternum from the 
second interspace and extends 7.8 cm. (3 inches) to the left of the mammary line, the 
impulse of the heart being in the seventh interspace. There is also extensive oedema of the 
lungs. The pulse is weak and feeble. It is very evident that there is an entire lack of 
compensation in this case, and that, unless the heart is quickly relieved, cardiac failure 
will take place and the child will die. I have therefore told the mother that paracentesis 
abdominis must be performed at once. 

(Subsequent history.) The mother refused to have paracentesis performed, and took 
the child home : it died suddenly on the following day from heart-failure. 

I have already referred to the deformities which may arise in the chest 
from the pressure of an enlarged heart during a period when the thoracic 
walls are still pliant and undeveloped. 

Here is a little girl (Case 506) who six years ago had an attack of rheumatism followed 
by endocarditis, and, although compensation has taken place and she is fairly well and 
strong, you see the displacement of the sternum and of the costal ends of the left ribs 
which has resulted from the cardiac enlargement. 



Case 506. 



Case 507. 





Displaced sternum and costal cartilages from 
enlarged heart. Female, 10 years old. 



Malformation of left side of thorax from 
cardiac disease. 



Here is another case (Case 507) of cardiac disease, in which the endocarditis with its 
resulting cardiac dilatation and hypertrophy occurred at a still earlier period of life, and, as 
you see, there is great deformity of the left side of the thorax produced by the intrathoracic 
pressure. 



1046 PEDIATKICS. 



L.KCTURE: IvII. 

DISEASES OF THE PERICARDIUM. 

The anatomy of the infant's pericardium, so far as I have been able to 
determine by the dissection of sixteen infants of various ages, appears to 
approximate so closely that of the adult that there is nothing distinctive 
to note concerning it. The amount of fluid which normally occurs in an 
infant's pericardium, although of variable quantity, is probably under 5 c.c. 

The chief diseases which affect the pericardium are hydropericardium, 
hsemopericardium, pneumopericardium, and pericarditis. The first three are 
very rare in early life, and therefore need be merely referred to. Absence 
of the pericardium may occur, and may be complete or partial. 

PERICARDITIS. — The most common disease of the pericardium is 
pericarditis. It can occur at all ages, but the earlier the age the less often 
is it met with. It has been found in the foetus and in the new-born, and 
well-marked adhesions of the pericardial surfaces have been observed in 
an infant which died thirty-six hours after birth. 

Etiology. — There are a number of organisms which seemingly give 
rise to pericarditis. The most common of these is the micrococcus lanceo- 
latus. In the new-born pericarditis may be the result of a septic condition 
following infection of the cord. At times it follows periostitis and ostitis 
in young children, here also probably being associated with septic infection. 
Traumatism may also be a cause of pericarditis. Rheumatism, especially 
after the third or fourth year of life, gives rise to as much periendocardial 
disease as at a later period. The inflammatory lesions may arise before the 
rheumatism has appeared elsewhere, and the intensity of the arthritic pain 
and the number of joints aflected do not correspond to, or rather do not 
influence, the frequency of the pericardial complication. Inflammation of 
the pericardium is also frequently associated with pneumonia. It may be 
secondary to any of the eruptive fevers, but occurs most frequently as a 
complication of scarlet fever. When it occurs in this latter disease it ap- 
pears usually in the second or third week of the attack. The pericardium 
also shows an especial tendency to invasion by the bacillus tuberculosis 
following tuberculosis of the pleura. 

Pathology. — Pericarditis may be circumscribed or diffuse, and there 
appears to be no essential difference between the pathological conditions 
affecting the pericardium in early life and those which occur later. The 
pericarditis sicca of the adult is comparatively unusual in the child, in whom, 
as a rule, an effusion of greater or less extent almost always takes place. 
The effusion may be sero-fibrinous, hemorrhagic, or purulent. Not only is 
the tendency to effusion in the child greater than in the adult, but its forma- 



DISEASES OF THE PERICARDIUM. 1047 

tion is characterized by greater rapidity and it is more likely to be purulent 
than in the adult. A pericardial effusion tinged with blood is not uncom- 
mon in early life, and is not necessarily so significant of tuberculosis as is a 
pronounced hemorrhagic effusion. The white, opaque thickenings of the 
inner pericardial surface so frequently found in adults are rare in children, 
but have been found at all ages, and where there is a deformity of the chest, 
as in certain cases of rhachitis, they have been especially noticed. Tuber- 
culosis of the pericardium as a primary disease is even more rare in the 
child than in the adult. Tuberculosis secondary to tubercle of the pleura 
may occur, especially when the left pleura is affected. The younger the sub- 
ject the less likely are there to be adhesions between the pericardium and 
the pleura, an important fact, to be taken into consideration later when I 
shall speak of the diagnosis of pericardial effusion in infancy. 

Symptoms. — Pericarditis may be acute or chronic, primary or secondary. 

The subjective symptoms of acute pericarditis in infancy are very 
indefinite, and throughout childhood this latency of the early symptoms is 
so marked and occurs so frequently that it may be said to be characteristic 
of the symptomatology of pericarditis in early life. It is so difficult to 
locate pain when it occurs in the infant, and a tumultuous action of the 
heart with general circulatory disturbance is so commonly the result of a 
diseased condition outside of this central organ, that it is impossible to 
formulate a practical general symptomatology for the onset of the disease. 
When, however, the disease has progressed, dyspnoea and orthopnoea become 
marked. Large effusions appear to affect the functional activity of the 
heart more rapidly in children than in adults, and to occasion earlier the 
signs of disturbance of the circulation. Diminution in the amount of the 
urine in cases of pericardial effusion, with a corresponding increase in the 
urine as the effusion decreases, has been noticed in children. The usual 
physical signs supposed to be characteristic of pericarditis are often very 
misleading, and where a pericardial friction-sound is absent the determina- 
tion of a case of pericarditis in a young child may present great difficulties. 
Owing to the flexible thorax of the child, there is a greater opportunity for 
the neighboring parts to yield before the pressure of an effusion, and we are 
more likely to have bulging of the intercostal spaces, and on inspection a 
visible alteration of the cardiac area, than in adults. Because of the small 
size of the child\s thorax, the heart and pericardium are much nearer to 
the anterior surface of the thoracic cavity than they are in adults. This 
occurs both normally and in diseased conditions, especially where tliere is 
flattening, and thus levelling, of the chest. Under these latter conditiiMis the 
heart and pericardium are brought in such close contact Avitli the thoracic 
wall that on palpation you can feel the heart's impulse, and on auscultation 
the heart-sounds, in a much more advanced stage of a pericardial effusion 
than would be possible in the adult with a proportionately large amount of 
fluid. It has also been noticed in early life that on auscultation the sounds 
in pericarditis and endocarditis simulate each other quite closely. L\n'cus- 



1048 PEDIATRICS. 

sion is the most important physical sign, when the initial friction-sound has 
escaped detection, both for determining whether an effusion is present and as 
a guide to the prognosis and treatment. In effusions of exactly the same 
amount the area of dulness may differ, owing to the difference in the elasticity 
of the lungs and to the presence or absence of adhesioiis. The greater the 
elasticity of the lungs and the fewer the adhesions the more regular will be 
the outline of absolute dulness and the greater its significance as compared 
with that of the relative dulness ; while the reverse of this proposition is 
true of the relative dulness. By absolute dulness I mean entire absence of 
resonance. By relative dulness I mean diminished resonance. The absolute 
dulness is determined by the retraction of the borders of the lungs, which 
withdraw from the chest-walls as the effusion gradually distends the peri- 
cardium. Relative dulness is due to the distended pericardium, and this 
to a greater or less degree compresses the lungs, which may be held 
in position by adhesions. The relative dulness, therefore, Avith its necessa- 
rily irregular outlines, varying according as adhesions are present or not, 
is most useful in studying complicated cases, while the absolute dulness 
should be relied upon in determining the outlines of the typical uncom- 
plicated cases. The older the individual the more likely are adhesions 
and pulmonary diseases to be present. These will either prevent the re- 
traction or alter the elasticity of the lung. The infant, being less likely 
to have had previous lesions of the lung and pericardium, gives us the 
best opportunity for studying the outlines of a pericardial effusion, and 
the area of absolute dulness is the most valuable physical sign of effusion 
in infants and in young children. It is evident, therefore, that we must 
acquire a precise knowledge of the uncomplicated cases before we shall 
be prepared to diagnosticate those in which adhesions are present or which 
are complicated by pulmonary disease. There is a great probability that 
many of the clinical observations on pericardial effusions made on adults by 
various competent clinical observers have been rendered of little practical 
value by the presence of adhesions, as has been proved by the difficulty in 
making a diagnosis by rules deduced from these observations. The num- 
ber of clinical observations on infants corroborated by post-mortem exam- 
inations is not yet large enough to provide us with sufficient data from 
which to make precise deductions, but the experiments on which are 
based the diagrams of pericardial elusion which I am about to show you 
were made on sixteen infants, in none of whom did adhesions exist. In all 
of these presumably typical cases absolute dulness was found to the right of 
the sternum. An instance of how the area of dulness varies in complicated 
cases was given by a case in which, although the pericardium Avas much 
distended with fluid, it failed to show dulness to the right of the sternum, 
and the autopsy revealed adhesions binding the lung tightly to the right edge 
of the sternum. In this case the effusion was behind the lung, and this 
permitted resonance to be obtained over an area Avhere in an uncomplicated 
case AA'ith the same amount of effusion there would have been duluess. 



DISEASES OF THE PERICAEDIUM. 1049 

In addition to the difficulties in making a differential diagnosis arising 
from interference with the contractility^ of the lungs, such complications as 
pneumonia of the right lung, especially its middle lobe, pleuritic effusion on 
the right side, an enlarged liver, and an enlarged heart must be considered. 
Where this pneumonia, or pleurisy, or hepatic enlargement is present, an 
eflfiision into the pericardium cannot be diagnosticated by means of percus- 
sion, but these diseases can iLsually be readily determined by their especial 
symptoms. The differential diagnosis, on the contrary, from an enlarged 
heart, especially a dilated heart where the murmur may be absent, can often 
be made only by means of percussiou. 

Experiments with artificial effusions on the cadavers of healthy indi- 
viduals should, therefore, first be made, and later further investigations be 
carried out, when possible, on indi\dduals in whom the various conditions 
which interfere with the typical percussion outlines of a typical case are 
present. It is doubtful if these latter investigations will be carried out for 
many years, owing to the apparently insurmountable dif&culties of pro- 
ducing these different abnormal conditions artificially. We can, however, 
learn much from the uncomplicated cases. Various methods of introducing 
fluids into the pericardium have been tried, and have failed to give satisfac- 
tory results. Although by dividing the sternum in the median line the 
pericardium can be entered without perforating the pleural cavity, yet when 
this method is employed the results of percussion are rendered void, since 
under these conditions air enters not only the anterior mediastinum but 
also the pericardium. The method which I finally devised and foimd to be 
most satisfactory in its mechanism was as follows. The infant was placed 
in the position of orthopnoea ; that is, the trunk was bent upon the lower 
limbs at an angle of about 120°. Tracheotomy was performed, and a 
clamped rubber tube was attached to the glass tracheal tube. The lungs 
were then inflated through this tube until on careful percussion the absolute 
area of cardiac dulness corresponded to that of a normal expiration. Under 
these conditions the area of absolute dulness, as you see in this diagram (Dia- 
gram 14, page 1050), begins at the junction of the upper border of the fourth 
left costal cartilage, and extends doAA nward and outward to the left in a 
curved line, with the convexity outward and keeping 2 or 3 cm. (} or IJ 
inches) within the nipple, until it joins the dulness of the left lobe of the liver. 
From the same starting-point at the fourth cartilage it extends downward in 
the left parasternal line, or rather within that line, towards the middle of 
the sternum, until it reaches the liver. The absolute dulness, therefore, is 
determine<l not by the shape of the heart itself, but by the marginal lines 
of the lungs, varying according to their expansion or retraction. This is a 
point which it is well to understand, — namely, that the pericardium itself, 
w^hether it is distended with fluid or not, does not by its own shape^ as 
has been delineated so often in the plates illustrating pericardial effusions, 
aid us materially in determining the shape of the area of absolute dulness 
in a pericardial effusion. This area is marked by the retracting or rather 



1050 



PEDIATRICS. 



displaced borders of the lungs. After the inflation was accomplished the 
tracheal tube was clamped so as to retain the lungs in position. An in- 
cision was then made in the median line of the abdomen, from the pubes up 
to within 2 cm. (f inch) of the ensiform cartilage. The liver and stomach 
were gently drawn away from the diaphragm, and on palpation of the cen- 
tral tendon of the diaphragm four centimetres to the left of the median line 



Diagram 14. 
Normal Thorax. 




^ A, physiological area of percussion-flatness of the heart on expiration ; HI B, liver ; ^ B', that 
portion of the liver which is covered by the right lung ; ^ C, lung ; S, sternum ; ^^ nipple ; 1, 2, 3, 
4, 5, 6, ribs ; --- (broken line), border of lung. 

the heart was felt. This point of the diaphragm was then carefully drawn 
down away from the heart, and a dagger-pointed trocar pushed through the 
diaphragm into the pericardial sac, which is adherent to the diaphragm at 
this point. Here is the trocar (Fig. 147) which, after many failures with 
other instruments, I finally devised, and have found to be satisfactory. 




Artificial pericardial eflfusion trocar (full size). 



The trocar is made of brass, with a conical point and a rounded shoulder 
forming the base of the cone, so that although it easily enters the pericar- 



DISEASES OF THE PERICARDIUM. 



1051 



dium it is difficult to withdraw it, the point acting like the barb of a fish-hook. 
A short piece of rubber tubing fitted tightly to the neck of the trocar can, 
as soon as the point and shoulder have entered the pericardium, be pushed 
up tightly against the under side of the diaphragm, thus holding the trocar 
in position, and the diaphragm, being firmly compressed between the shoul- 
der and the rubber tube, prevents the entrance of air. The trocar is con- 
nected by means of a piece of rubber tubing, which is also provided with 
a clamp, to a simple wash-bottle graduated for cubic centimetres and con- 
taining melted cacao butter. Before introducing the trocar the cacao butter 
is allowed to fill the tubing and the trocar so as to displace the air. As 
soon as the trocar has entered the pericardium the tracheal tube is un- 
damped, in order that the lungs may be free to retract before the fluid. 
When sufficient fluid, as indicated by the graduated bottle, has entered the 
pericardium, the cacao-butter tube and the tracheal tube are again clamped, 
the thorax is carefully percussed, and the line of absolute dulness is marked 
in ink. After twenty-four hours the sternum is removed from above down- 
ward, remaining attached below, and we find the lungs in position surround- 

DlAGRAM 15. 




Small amount of liquid introduced into sac (Rotch). ^ A, the portion of the area of absolute dul- 
ness which is still caused by the physiological dulness of the heart ; lUlf B, liver ; ^ B', that portion of 
the liver which is covered by the right lung ; r^ C, lung ; ^ D, effusion ; A + D, area of ateolute 
dulness found when the effusion is small; S, sternum; (^, nipple; 1, 2, 3, 4, 5, 6, ribs; --- (broken 
line), border of lung. 

ing the hardened fluid. I have represented in this diagram (Diagram 1 5) 
the relations of the lung and the pericardium where a small amount of fluid 
has been introduced. 



1052 



PEDIATRICS. 



By replacing the sternum and verifying by means of needles penetrating 
the lines marked in ink, we can determine accurately the shape of the area 
of absolute dulness with this amount of effusion, which represents the re- 
sults obtained when from 70 to 80 c.c. (2^ to 2|- ounces) of fluid were intro- 
duced into the pericardium of an adult. There is a slight increase in the 
vertical as well as in the transverse area of dulness. The curved line which 
bounds the area of dulness starts at the sixth rib, to the right of the 
sternum, passes upward to the junction of the fourth cartilage with the ster- 
num, impinges on the lower part of the third left interspace, and then 
descends just outside of the mammary line to the sixth rib, to pass in- 
ward until it meets the dulness of the left lobe of the liver. This line 
forms, as you see, an irregular semicircle, with a shorter radius to the right 
of the sternum and a longer one to the left. It is important to understand 
what causes this area of absolute dulness. This you can best do by refer- 
ring to this next diagram (Diagram 16), where with the same amount of 



Diagram 16. 




The luBgs have been removed (Rotch). ^ A, portion of the normal heart enclosed in the pericar- 
dium ; mill B, liver ; ^ D, effusion as it appeared in the sac, the cacao butter being in small amount, 
and the lungs having been removed after the butter had hardened ; S, sternum ; (^, nipple i 1, 2, 3, 
4, 5, 6, ribs. 

effusion the lungs have been removed, leaving the heart and the distended 
pericardium exposed to view. 

It will be seen on comparing the diagrams that a small section of the 
dull area, corresponding to the junction of the fourth and fifth ribs with 
the left side of the sternum, is formed by the heart itself, which is free 



DISEASES OF THE PERICARDIUM. 1053 

from effusion at this point, while the rest of the dulness is produced by the 
effusion. On examining also the hardened cacao-butter cast of this effusion, 
it was found that the layer of fluid was very thin all over the upper por- 
tion of the effusion in the region of the fourth rib and fourth interspace, while 
the mass of the effusion, as shown by the greatest thickness of the cacao 
butter, was, as would be expected from the laws of gravity and the shape 
of the pericardium, in the lower part of the sac on each side of the sternum 
in the fifth interspaces, the cast riding the arched diaphragm like a saddle, 
and the larger part of the mass being on the left side. These points should 
be carefully noted, as they are significant for diagnosis and treatment. 

The same result as to the area of dulness was obtained with a propor- 
tionately small amount of fluid in an infant about two weeks old ; and 
of sixteen injections, of infants of various ages, the areas of dulness were 
identical in all, and in all the lungs were normal and there were no pulmo- 
nary or other adhesions. 

This next diagram (Diagram 17) represents the position assumed by the 

Diagram 17. 




A large amount of liquid has been introduced into the sac (Rotch). |||||j B, liver; ^ B', that por- 
tion of the liver which is covered by the right lung ; i'})^ C, lung : ^ D, the area of absohite dulness 
caused by a large effusion ; S, sternum ; (^, nipple ; 1, '2, 3, 4, 5, 6, ribs : - - - (broken line), border of limg. 

margins of the lungs and the resulting area of absolute dulness where tlie 
pericardium was distended with a large amount of fluid so as to cover the 
entire heart. 

Here the transverse area of dulness produced by the much distended 



1054 



PEDIATRICS. 



pericardium has increased so that it extends farther to the right of the ster- 
num in the fourth and fifth interspaces, and then, rising to the third inter- 
space, it occupies a small area on either side of the sternum under the third, 
second, and first ribs and the second and first interspaces, the upper lobes 
of the lungs having retracted from beneath the sternum. As the eifusion 
increases the lungs retract still more, and the upper curved lines of the effu- 
sion on either side of the sternum present areas with still greater diameters. 
This next diagram (Diagram 18) represents this same large effusion with 
the lungs removed, and also shows the relations of the heart and great 
blood-vessels to the ribs and sternum before the pericardium has been dis- 
tended with fluid. 

Diagram 18. 




The lungs have been removed (Rotch). ^ A, normal shape of the heart in its pericardium ; H B, 
liver ; Q D, eflFusion ; A + D, the shape which the pericardium assumed in a case where considerable 
fluid had been iutroduced into the sac ; S, sternum ; ^ nipple ; 1, 2, 3, 4, 5, 6, ribs. 



As ordinarily seen on the injected subject, the heart would of course not 
appear as in the diagram, as it really was suspended in the pericardial sac 
with the effusion surrounding it and causing the entire area of dulness 
represented by A and D. 

The fact that on opening the abdomen the diaphragm remains arched, 
and that the lung, by means of the tracheal clamp, retains its position and 
does not collapse, warrants us in assuming that we can fairly judge of the 
position of the fluid during life by this method of investigation, especially 
as the contractility and distensibility of the lung appeared to be perfectly 
retained after death, except in very cold weather, when it was found neces- 



DISEASES OF THE PERICARDIUM. 1055 

sarv to warm the cadaver. It might have been objected to these experi- 
ments that the fluid was introduced at the bottom of the pericardial sac, 
while during life it might originate at the base of the heart. The fluid 
waSj therefore, in several cases introduced where the pericardium is reflected 
over the great vessels ; but even when it was in very small amount and 
insufficient to cause any increase of dulness, it immediately ran down the 
side of the heart to the bottom of the pericardium. Even when it was 
mechanically retained at the base of the heart by inverting the cadaver, 
the resulting cast had its broadest part towards the diaphragm. 

Diagnosis. — From what I have told you regarding the latency of the 
general symptoms of pericarditis in childhood and the difficulty of inter- 
preting the local symptoms, it will be readily understood how important it 
is to recognize any especial symptoms which may characterize the disease. 
Instances have been reported where a distended pericardium was mistaken 
by experienced diagnosticians for an effusion into the left pleura. 

The condition, however, which most closely simulates a pericardial effu- 
sion, both in its general symptoms and in its physical signs, is a dilated heart. 

The most distinctive of all the physical signs of pericarditis is the fric- 
tion-sound, when it is present. When, however, an effusion has taken place, 
the friction-sound may not be heard. This absence of a friction-sound is 
especially frequent in young children. The heart's impulse may be clearly 
perceptible, even when a considerable effusion is present, owing to the thin 
layer of fluid which covers the heart in the area between the left nipple 
and the sternum. We are therefore forced by the similarity which at times 
exists between the general symptoms, in the inspection, palpation, and aus- 
cultation of a dilated heart and of a pericardial effusion, to depend upon 
percussion in making a differential diagnosis. In order, however, to make 
a differential diagnosis between this area of percussion and that produced 
by an enlarged heart, it will be necessary to consider the possible area of 
dulness which may be produced by an enlarged heart, and, by' comparing 
this area with that which I have shown to exist in a pericardial effusion, 
to determine the differential diagnosis between the two diseases. 

According to careful observations which have been made by competent 
observers on the area of dulness which can be produced by an enlarged heart, 
whether by hypertrophy or by dilatation, ventricular or auricular, although 
the relative dulness mav extend to the rio-ht of the sternum from the second 
to the sixth rib, and in adults possibly to the distance of 3 or 4 cm. (IJ or 
1 J inches) on a level with the fourth rib, yet it is rare to find this dulness 
invading the fifth right interspace more than 2 or 3 cm. (f or 1 J inches), and 
still more rare for the absolute dulness to be found in the fifth interspace at 
all, and even in the fourth interspace for more than 1.5 or 2 cm. (J or |- inch). 

This diagram (Diagram 19, page 1056) represents the combined views of 
authorities on the dulness of an enlarged heart, and \nll be useful to refer to 
when we are considering the question of paracentesis. I have myself fre- 
quently verified these percussion-outlines, and in my experience it is exceed- 



1056 



PEDIATRICS. 



ingly rare, even in extreme cardiac enlargement, to find the relative dulness 
E E' E^' of as great an extent as is represented in this diagram. The abso- 
lute dulness as represented in the diagram I have met with in most cases 
of enlarged heart where the enlargement is great and the sternal region is 
involved. 

Diagram 19. 




Enlarged heart (Rotch), ^ A, area of absolute dulness caused by an enlarged heart ; |||||| B, liver; 
^ B', that portion of the liver w^hich is covered by the right lung ; K}'^ C, lung ; E E' E", the line 
marking the area of relative dulness of the enlarged heart ; Sf sternum ; ^, nipple ; 1, 2, 3, 4, 5, 6, 
ribs ; --- (broken line), border of lung. 

On referring to Diagram 17, we find that the dulness which occurs in a 
pericardial effusion may correspond to that of an enlarged heart through its 
whole area, but that the dulness of the effusion is also found in an additional 
area corresponding to a part of the fifth rib and fifth interspace. Absolute 
dulness, therefore, in the fifth right interspace 3 or 4 cm. (IJ or IJ inches) 
from the right parasternal line in cases of pericarditis uncomplicated by 
pleural or pericardial adhesions becomes a valuable means of differential 
diagnosis from an enlarged heart. 

I have found in my experiments on the adult pericardium that the abso- 
lute dulness could be detected in the fifth right interspace when from 70 to 
80 c.c. of fluid had entered the pericardium. 

In order to illustrate to you the difference between the area of dulness 
produced by an enlarged heart and that produced by a pericardial effusion, 
I have marked on this boy (Case 508, page 1057), eleven and a half years 
old, the boundaries of the area of absolute dulness in an enlarged heart, in 
a small pericardial effusion, and in a large pericardial effusion. 



DISEASES OF THE PERICABDIUM. 1057 

I have indicated the top of the sternum, the boundaries of the enlarged 
heart, the ensiform cartilage, and the lower border of the ribs by plain 
black lines, the boundaries of the small effusion by a broken line, and the 
area of the large effusion by a larger broken line. The figure 5 marks the 

Case 508. 




Areas of absolute dulness in enlarged heart, and in distended pericardium. 5, fifth right interspace ; 

H, heart. 

fifth right interspace ; the letter H marks that portion of the heart which 
has been left uncovered by the small effusion. The small black circle rep- 
resents the normal position of the apex of the heart, the larger circle the 
apex of the enlarged heart. You will also notice how the enlarged heart 
extends beyond the right edge of the sternum at about the fourth rib and 
fourth interspace, and then returns beneath the lower part of the sternum 
within or very little outside of the right parasternal line. The outline of 
the small effusion, as well as that of the large effusion, is, as you see, to the 
right of the sternum as low as the sixth rib. 

The following cases (Table 111, page 1058), taken from a number which 
have come under my care, illustrate the difficulty of making a differential 
diagnosis between cardiac and pericardial disease where, as at times happens, 
we fail to find a friction-sound or murmurs : 

67 



1058 



PEDIATRICS. 



TABLE 111. 

Differential Diagnosis between Dilated Heart and Pericardial Effusion. 



Case I. 
Endocarditis; Dilated Heart. 



Girl, eleven years. 

Attack followed acute artic- 
ular rheumatism. 

Orthopnoea ; prsecordial pain. 

Heart's impulse feeble, but 
perceptible a little to left 
and below left nipple, fifth 
interspace. 

Vertical absolute dulness not 
increased. 

Absolute dulness under the 
sternum and to left of 
sternum ; identical with 
Cases II. and III. 

Absolute dulness did not ex- 
tend to right of sternum. 



Systolic murmur at apex. 



Eecovery. 



Case II. 
Pericarditis ; Efiiision. 



Boy, six years. 

Attack followed acute artic- 
ular rheumatism. 

Orthopnoea; prsecordial pain. 

Heart's impulse feeble, but 
perceptible a little to left 
and below left nipple, fifth 
interspace. 

Vertical absolute dulness not 
increased. 

Absolute dulness under the 
sternum and to left of 
sternum ; identical with 
Cases I. and III. 

Absolute dulness in fifth 
right interspace two or 
three centimetres from 
edge of sternum. 

Pericardial friction-rub at 
base. 



Kecovery. 



Case III. 

Endocarditis ; Enlarged Heart : 

Pericardial EflFusion. 



Girl, eight years. August 3, 
1887. 

Attack followed acute articular 
rheumatism. 

Orthopnoea ; prsecordial pain. 

Heart's impulse feeble, but per- 
ceptible all over cardiac area, 
with apex-beat a little below 
and to left of left nipple, fifth 
interspace. 



Vertical absolute dulness 
increased. 



not 



Absolute dulness under the ster- 
num and to left of sternum ; 
identical with Cases I. and 
II. 

Absolute dulness in fifth right 
interspace three or four cen- 
timetres from edge of ster- 
num. 

Soft systolic murmur at apex, 
transmitted to axilla. Peri- 
cardial friction-rub at base. 

August 6 : Less dulness in fifth 
right interspace ; apex mur- 
mur much louder and harsh. 

August 11 : Dulness only to 
right edge of sternum. 

August 18 : Dulness only to 
middle of sternum ; friction- 
rub ceased. 

December 1, 1887: Physical 
examination the same as on 
August 18, showing enlarged 
heart and mitral systolic mur- 
mur. 



You will observe that the symptomatology, both general and local, of 
these cases was, with the exception of the friction-sounds, murmurs, and 
percussion, identical, and that where an eflPusion was present dulness was 



DISEASES OF THE PERICARDIUM. 1059 

found in the fifth right interspace, while where it was absent dulness was 
not found. These typical cases with friction-sounds and murmurs were 
simply chosen in order that there should be no doubt as to the disease with 
which I was dealing when testing the value of percussion as a means for 
differential diagnosis. 

I have referred to pericarditis with its accompanying effusion as being 
likely to occur in the later stages of scarlet fever. According to Steffen, 
when dilatation of the heart occurs in the later stages of scarlet fever, in 
cases where from the age of the child, three to eight years, the physiological 
hypertrophy of the heart is present, the tendency to enlargement is still 
fiu'ther promoted by the increased blood-pressure from the diseased kidney, 
and a differential diagnosis between a pericardial effusion and an enlarged 
heart thus becomes necessary. 

In connection with pericarditis we should consider the possibility of 
both complete and partial obliteration of the pericardial cavity occurring in 
children. Where severe cardiac symptoms are present and no vah^iilar 
murmurs are heard, we should in young children think of degeneration of 
the heart-muscle itself or of pericardial adhesions. When, again, the abso- 
lute area of dulness remains unchanged and there are well-marked systolic 
retractions, the presence of pericardial adhesions is highly probable. 

While in older children and in adults pericarditis is manifested by 
weakness of the apex-beat, the latter sometimes being imperceptible, and by 
a friction-sound, in very young children these symptoms are often absent, 
because the exudation is moderately thick and may not be abundant enough 
to cause friction-sounds or to mask the apex-beat. 

Chronic pericarditis may occur in infancy and in childhood as in adult 
life, and is the result of acute inflammatory processes which have resulted 
in adhesions. It is often very latent, as is shown by autopsies. 

Prognosis. — In early infancy diffiise pericarditis is a very dangerous 
disease, and usually soon ends fatally. In later childhood its course and 
results are much the same as in adults, and in the acute form the disease 
has a tendency to recovery. Among the imfavorable complications of the 
disease which render the diagnosis especially serious may be mentioned adhe- 
sions of the two layers of the pericardium, which may paralyze the cardiac 
muscles and from the resulting stasis of blood may lead to extensive 
dropsy. The principal symptoms of this form of cardiac paralysis are a 
small and frequent pulse, subnormal temperature, oedema of the cheeks, 
Kds, and lower extremities, and the presence of a small quantit\^ of albimiin 
in the urine. 

Treatment. — The treatment of pericarditis in infancy and in early 
childhood does not differ materially from that in later life, and depends 
upon the various causes which I have referred to in speaking of the eti- 
ology of the disease. The tendency to heart-failure, however, which is so 
pronounced in the child, should be guarded against. Early in the dis- 
ease absolute physical and mental rest should be enforced. In the acute 



1060 PEDIATRICS. 

stage of the disease, before an eifusion of any extent has formed, cold can 
be applied to the cardiac region by means of coils of tubing containing ice- 
water. An important part of the treatment is the judicious administration 
of digitalis to aid the heart in the crippled condition in which it is usually 
left after the early days of the disease. Stimulants should be freely used 
when there is any indication of heart-failure. 

The most important part of the treatment when an effusion of any 
extent has occurred is paracentesis of the pericardium, which should unhesi- 
tatingly be performed, no matter what the cause of the disease may be, when 
life is in danger from undue distention of the pericardial sac. The pericar- 
dium has usually been aspirated to the left of the sternum. The possibility 
of wounding the heart when the aspiration is made to the left of the ster- 
num should be considered, and, if possible, avoided. An important point 
both in the diagnosis and in the treatment should be here spoken of. It 
has been held by certain authorities that the heart's apex is found in 
effusions to be tilted upward and inward towards the sternal end of the 
fourth left interspace, — that is, floated up by the effusion. Direct proof 
of this is wanting, and I believe, from my investigations on this subject, 
that it is an erroneous view. It would seemingly be impossible for the 
heart not to sink rather than to be floated up, unless the specific gravity 
of the effusion was greater than 1050, as I have shown by experiment. It 
is highly improbable that the specific gravity would be greater than 1050 
in an ordinary pericardial effusion, for the specific gravity of a purely 
purulent fluid is only about 1032. How, then, can we explain the clinical 
phenomenon of the heart-beat in the region of the fourth left interspace, 
where it is so frequently found in cases of pericardial effusion ? Referring 
to Diagrams 15 and 16, and to Case 508 (pages 1051, 1052, 1057), it seems 
plausible to account for this pulsation by the tumultuous action of that por- 
tion of the right ventricle which is seen to be free from the effusion in the 
fourth left interspace when an effusion of any extent is present. 

On examining the cacao-butter casts it is also found that this portion of 
the heart is in the larger effusion, as I have already described to you, 
covered by a very thin layer of fluid, through which the impulse of the 
heart can easily be felt and seen. This fact is of especial significance when 
we consider that both Ludwig and Bowditch have observed that the impulse 
of the heart as seen normally in the fifth left interspace need not be caused 
by the heart's apex, but may be caused by a portion of the heart above the 
apex striking against the thoracic Wall. We should also consider that the 
impulse of the heart in children is often chiefly in the fourth interspace. In 
Case III. described in this table (Table 111, page 1058) it is recorded that 
the impulse was found through the whole cardiac area, but that it was still 
pronounced in the fifth interspace. Now, if in this case there had been a 
larger effusion, the apex and the lower segment of the right ventricle being 
surrounded by a mass of fluid, the impulse would have been lost in the fifth 
interspace, while in the fourth interspace, where the ventricle is covered by 



DISEASES OF THE PERICAEDIUM. 1061 

only a thin layer of overlying fluid, the impulse would have continued to be 
both seen and felt, thus simulating an apex-beat. I believe that this is the 
explanation of what has been called misplaced apex-beats and floating 
upward of the heart in pericardial effusions. 

From the above facts, — namely, that the heart, when an effusion is pres- 
ent, remains in its usual position, and does not, even when much enlarged, 
impinge on the fifth right interspace, and that the effusion, even when in so 
small an amount as 100 c.c, is found in the fifth right interspace, — is it not 
more rational to choose the fifth right interspace as the point for tapping, 
thus avoiding all question of injuring the heart ? When we tap the pleura, 
we avoid the heart as much as possible : why not carry out the same rule in 
paracentesis of the pericardium ? I have tapped the pericardium in the fifth 
right interspace a number of times on the cadaver, and have removed the 
fluid as easily as in the fifth left interspace. 

The pericardium has been tapped during life in the fifth right interspace 
by Ebstein, of Gottingen, and Wilson, of Nashville. 

As an illustration of how important it is to tap the pericardium when it 
is much distended with fluid and when symptoms of failing heart have arisen, 
I shall report to you a case which occurred a few days since in the wards. 

A boy (Case 609), six years old, entered the hospital with a history of having had 
oedema of the face, hands, feet, and ankles for four weeks. There was no history of rheu- 
matism, and the case was apparently one of acute primary endocarditis with mitral insuf- 
ficiency. The cardiac area of dulness was increased, and extended from the middle of the 
sternum to 1.5 cm. [^ inch) beyond the left mammary line, where the impulse of the heart 
could be felt. The child was kept quiet in bed, and after a few days the oedema lessened 
and he was very comfortable. While still under treatment, two weeks later, the tempera- 
ture, which had been normal, rose to 39.1° C. (102.5° F.), the pulse was quickened and 
somewhat irregular, and the respirations were increased. A few days later a pericardial 
friction-sound was heard over the upper part of the sternum, and the temperature fell to 
37.7° C. (100° P.). There was no change in the cardiac area of dulness, and no evidence 
of a pericardial effusion. 

On the following day the cardiac sounds were found to be rather muffled ; the child did 
not seem so well, and was unable to lie on his left side. Two days later the area of praecor- 
dial dulness extended farther to the right, and a little beyond the right parasternal line in the 
fifth right interspace. The attendants were directed to watch the child closely, and warn- 
ing was given that the necessity for paracentesis of the pericardium might at any time arise. 
Early the following morning the child began to have marked dyspnoea and became very 
cyanotic. The house-officer found that the prsecordial dulness had extended 2.7 cm. (1 inch) 
beyond the right edge of the sternum in the fifth interspace, and he therefore got the 
instruments ready for performing paracentesis. Suddenly the child's pulse became very 
weak and intermittent, the cyanosis increased very much, the dyspnoea became very marked, 
and, although stimulants were quickly given, the child suddenly gasped and fell back on its 
pillow dead. This occurred within three-quarters of an hour from the time when the first 
serious symptoms arose. The house-officer, Dr. Stickney, immediately introduced the 
aspirating needle in the fifth right interspace and withdrew some fluid from the pericardium. 
The child, however, did not revive. 

This case of pericardial effusion, as well as the case of pleuritic effusion (Case 481, 
page 1011), should warn us that whenever a pleural or a pericardial cftusion is present the 
child should be watched with the greatest care, and paracentesis should be performed as 
soon as any urgent symptoms arise. 



1062 PEDIATRICS. 

Here is a little girl (Case 510), six and one-half years old. She has never had rheuma- 
tism, but she had an attack of measles when she was two years old, pertussis when she was 
two and a half years old, and parotitis when she was three and one-half years old. Four 
months ago she had an attack of chorea, of so mild a grade, however, that she has been 
able to go to school until entering the hospital. At that time, although she did not show 
any especial cardiac symptoms, an examination of the heart showed a latent and insidious 
endocarditis, represented by an increase of the cardiac area of dulness to the left of the 
mammary line, but not extending under the sternum, with a systolic murmur transmitted 
to the axillary line, but not heard in the back. Compensation soon became complete, and 
she recovered from the chorea. 

Two days ago she was attacked with dyspnoea, rapid respirations, and cardiac pain. 

Case 510. 




Chronic endocarditis. Mitral insufficiency. Pericarditis sicca. F, pericardial friction-sound ; 5, fifth. 

right interspace. 

On examining her to-day the child seems very sick, and in addition to the area of 
cardiac dulness which I have marked in black, and which, as you see, shows the presence 
of a dilated heart, I find at the junction of the third rib with the sternum a marked 
prsecordial friction-sound. 

(Subsequent history.) The precordial pain, discomfort, and heightened temperature 
lasted for a few days, and were in the beginning accompanied by orthopncea and by the fric- 
tion-sound becoming more intense. There was at no time, however, any evidence of an 
effusion in the pericardium, and one week afterwards the friction-sound became less distinct, 
disappearing three days later. The child, however, grew much weaker, and, although she 
was treated by complete rest in bed and with digitalis, strophanthus, and stimulants, the 
prsecordial pain returned, and she gradually failed and died. The chart (Chart 46, page 
1063) shows the temperature during the attack of pericarditis. The pulse varied from 130 
to 150, and the respirations from 50 to 80. 

The autopsy showed the pericardial sac to be obliterated everywhere by firm fibrinous 
adhesions. The heart was enlarged. Along the edge of the mitral valve were numerous 
small grayish-white vegetations. These were also present on the aortic valves and on the 
portion surrounding the tricuspid valve. The lungs were denser than normal, and were 
deeply injected and oedematous. The pleura on the inner surface of the right lower lobe was 



DISEASES OF THE PERICARDIUM. 



1063 



adherent to the pericardium by fibrinous adhesions. The surface of the liver was covered 
with a thin layer of fibrin. The liver and kidneys were a little denser than normal, but 
were not noticeably congested. 

CHAKT 46. 





Days of Disease. 




F. 


1 


2 


3 


4 


5 


6 


7 


8 


9 


10 


ll|l2 13 


14 15 


16|l7 


18|l9 20 21 


c. 


107 
106 
105 
104 
103 
102 
101 
100 
99 

NORM' 
TEMP. 

98 
97 

96 
95 


ME 


M E 


ME 


ME 


M E 


M E 


M E 


M E 


ME 


M e'm E 


ME 


ME 


M E 


M E 


M E 


ME 


M E 


ME 


MEME|i 1 












































41.1° 
40.5° 
40.0° 
39.4° 
38.8° 
38.3 
37.7° 

|37.0 
36.6 

36.1° 

35.5° 
35.0° 


































- 








1 






















































































/ 








■ 


































/ 


^ 




y 




y 


/ 


/ 


/ 


/[ 


y 




/ 


/ 
















/ 






(^ 


k 


/ 


/ 


[/ 


/ 




[/ 


1/ 


/ 


/ 








/ 


/ 




/ 


/ 




/ 




N 


( 






/ 


/ 






Y 


Y 


/ 


,/M 


/ 


/ 


/ 


V 


/ 




/ 
























/ 


/ 


/ 
























































■ 








■■ 









































































































Pericarditis sicca. 

Anatomical Diagnosis. 

Chronic adhesive pericarditis. 
Acute vegetative endocarditis. 
Acute fibrinous pleurisy. 
Acute fibrinous perihepatitis. 
Hypertrophy and dilatation of the heart. 



Here is a little girl (Case 511), eight years old, who during the first two years of her life 
had scarlet fever, varicella, and pertussis. "When she was two years old she had an attack 
of measles, and when she was seven years old an attack of chorea. During the last year 
she has been fairly well until two weeks ago, when it was noticed that her feet began to 
swell, she complained of pain in her limbs, and occasionally of headache, she lost in weight, 
and lately has had orthopnoea with frequent paroxysms of dyspnoea. She has also at times 
complained of pain in her left chest. Her extremities are apt to be cold. For the past two 
days she has had a short, dry cough. A physical examination shows the impulse of the 
heart to be feeble, but it can be felt all over the cardiac area. There is an area of precordial 
dulness extending to the right of the sternum almost to the right mammary line, as low as 
and involving the fifth interspace and as high as the third interspace and to the left a little 
beyond the left mammary line to the sixth rib. There is a systolic murmur at the apex, 
which is transmitted to the axilla. The pulmonic second sound is accentuated. There is a 
prsecordial friction-sound heard at the upper part of the sternum. The history of the case 
and the area of precordial dulness show us that it is a case of pericarditis with effusion. 
There may also be some endocarditis, evidence of which is given by the mitral systolic 
murmur. The child is being treated by rest in bed and by digitalis. 

(Subsequent history.) Two weeks later the friction-sound disappeared, and the pneoor- 
dial dulness grew less, so that it extended only to the middle of the sternum. In the next 
two weeks the dulness beneath the sternum disappeared, and the mitral murmur lessened, 
but could still be heard 2 cm. (| inch) outside of the mammary line. 



1064 



PEDIATRICS. 



This chart (Chart 47) shows the irregular temperature during seven days of the peri- 
cardial effusion. 

CHAKT 47. 





Days of Disease. 




m. 
















c. 


107° 
106° 
105 
104 
103 
102° 
101 

100° 

99 

NORMAL 
TEMP.^ 

98 
97° 
96 

95° 


ME 


M E 


M E 


ME 


M E 


ME 


ME 


41.6 

41.1 

40.5 

40.0 

39.4 

38.8 

38.3 

37.7 

37.2 
37.0 
36.6 

36.1 
35.5 
35.0 
















































l 


' 












/ 










/ 




/ 










/ 


/ 


/ 


/^ 








/ 








X^ 


/ 


^ 


/ 

































































Pericarditis with, eifusion. 



Divisio:Nr XVIII 

UNCLASSIFIED DISEASES. 



IvKCTTURK LIII. 

Ehachitis. — Scorbutus.— Eheumatism. — Purpura. — Diabetes. — Tuberculosis. — 
Epidemic Influenza. — Diseases of the Thyroid Gland. — Diseases of the 
Cervical Lymph Glands. — Parotitis. — Diseases of the Ear. 

I SHALL now speak of a number of diseases which are not readily 
classified under the divisions that I have found most useful for teaching, 
and which will therefore have to be spoken of separately. 

EHACHITIS. — Ehachitis is a disease of infancy, rarely of early child- 
hood, and is closely associated with impaired nutrition. It shows itself 
mostly in alterations of the growing bones. Its most marked symptoms are 
met with betrveen the sixth month and the second year, but it can occur at 
all ages, and may be congenital. 

Etiology. — Although the cause of rhachitis is not yet clearly under- 
stood, it is evidently closely connected with interference with the nutrition by 
improper food and lack of suitable hygienic surroundings. Although it 
most frequently exists after the first six months of life, yet probably many 
cases occur earlier, but are so mild in form that the rhachitic lesions do not 
become sufficiently marked for recognition until the latter part of the first 
year. It is well known that rhachitis is much more common in its occur- 
rence among all classes of life than was formerly supposed. As a con- 
genital disease it is probably associated with lack of proper intra-uteriue 
nourishment, corresponding to the rhachitis which is met with in cases of 
prolonged lactation. Like all diseases associated with impairment of nutri- 
tion, it is less likely to occur among breast-fed infants than among those who 
are deprived of their natural food. For the same reason it is more likely 
to develop in the latter part of the first year than in the early months, since 
in so many cases the breast-milk deteriorates in quality after the first six or 
seven months of lactation. The disease seems to occur where the food is 
not properly adapted to the especial age. Certain races, sucli as the lower 
classes in Italy and in England, are notably affected by rhachitis. The 
disease in a marked form is not common among native-born Americans. 

1065 



1066 



PEDIATRICS. 



Pathology. — Although there are lesions of the various organs which 
seem to be closely connected with rhachitis, such as enlargement of the 
spleen and of the liver, yet the bones show so markedly the most important 
changes that practically and clinically, in the present state of our knowledge 
concerning the disease, these changes in the bones constitute its pathology. 
We must remember, however, that the nutrition of all the tissues is pro- 
foundly affected, and that the equilibrium of the nervous system is very 
unstable. 

According to Delafield and Prudden, the growth of the bones depends 
upon three conditions. They grow in length by the production of bone in 
the cartilage between the epiphysis and the diaphysis, and in thickness by 
the growth of bone from the inner layers of the periosteum. At the same 
time the medullary canal is enlarged in proportion to the growth of the 
bone by the disappearance of the inner layer of bone. In rhachitic chil- 
dren these three conditions are abnormally affected. The cartilaginous and 
subperiosteal cell growth which produces ossification goes on with increased 



-z. p. 





z.p. 



I. Normal bone : Z. P., zone of proliferation. II. Bone of a cretin : Z. P., zone of proliferation. 
III. Rhachitic bone : Z. P., zone of proliferation. 

rapidity and in an irregular manner both between the epiphysis and the 
diaphysis and beneath the periosteum, while the actual ossification is markedly 
irregular or wanting. At the same time the dilatation of the medullary 
cavity goes on irregularly and often to an excessive degree. If we examine 
microscopically the region between the epiphysis and the diaphysis usually 
called the zone of proliferation, we find that the cartilaginous cells are not 
regularly arranged in rows around a definite zone in advance of the ring of 
ossification, as in normal tissue, but that there is an irregular heaping up 



UNCLASSIFIED DISEASES. 



1067 



Fig. 149. 



of cartilaginous cells, sometimes in rows, sometimes not, covering an ill- 
defined irregular area. This zone of proliferation also, instead of being 
narrow and sharply defined, is quite lacking in uniformity. Areas of cal- 
cification may be isolated in the region of the proliferating cartilaginous 
cells, or calcification may be altogether absent over considerable areas. 

Here is a section of a normal bone (Fig. 148, I.) taken from an infant 
which shows the normal zone of proliferation (Z. P.) between the epiphysis 
and the diaphysis. 

Here also is a section of a rhachitic bone (Fig. 148, III.) which shows 
the broad, irregular, and abnormal zone of proliferation (Z. P.) which I 
have just described. 

Here is a section of another rhachitic bone (Fig. 149), which shows 
the great enlargement of cartilage at the epiphysis, with the irregular foci 
of calcification. The diaphysis of the bone shows 
periosteal thickening to such an extent that it en- 
croaches on the medullary cavity, which, as you see, 
is much diminished. 

An excessive proliferation of cells in the inner 
layers of the periosteum, the irregular calcification 
which occurs about them, and the absence of uni- 
formity in the elaboration of the structure of the 
bone, produce an irregular, spongy bone-tissue in- 
stead of the compact lamellated tissue which is so 
necessary for the uniformity of the structure. The 
increased cell- growth between the epiphysis and the 
diaphysis produces the peculiar knobby swellings 
which are characteristic of rhachitis. At the same 
time the medullary cavity increases rapidly in size, 
and the inner layers of the bone become spongy. 
The medulla may be congested, and fat, if it has 
formed, may be absorbed, and a species of osteitis 
ensue. The result of these processes is that the 
bones do not possess solidity and cannot resist the 
strain of the muscles or outside pressure. After a 
time the rhachitic process may stop and the bones 
may assume a more normal character. The porous 
bone-tissue becomes compact, and even unnaturally 
dense, so that in later childhood the rhachitic bone 
is unusually hard, like ivory, a condition noticed by 
those who have to operate on these bones. 

The swelling at the epiphyses disappears as the 
disease passes off. Many of the deformed bones may 
become of a normal shape, but in severe cases the 
deformity may continue through life, especially if there is a cessation of 
the growth of the bones in their long axes, so that the ohikhvn are dwarfed. 




Spindle-shaped rhachitic 
Ixme. 



1068 



PEDIATRICS. 



The first signs of rhachitic disease are always found in those parts of 
the bones which are in the most active stage of development. In the early 
days of extra-uterine life the skull undergoes the most marked changes. 
The cranium may be unusually large for the size of the face. The fonta- 
nelles and sutures are widely open. The bones may be soft, porous, and 
hypersemic, while at their edges there may be rough bony projections beneath 
the periosteum. Sometimes, especially in the occipital bone, there are 
rounded defects in the bone filled only with a fibrous membrane. This 
constitutes what is called craniotabes. The head itself is usually large and 
square, in contradistinction to the hydrocephalic head which I showed you 
at an earlier lecture (Case 286, page 638), and which in consequence of the 
eversion of the parietal bones has a globular shape. In the rhachitic head 
the parietal bones are more vertical, thus giving the square appearance. 

The forehead is sometimes very prominent, and the normal thickness of 
the bones is increased by means of a large amount of new periosteal soft 
gro^vth between the periosteum and the bones, which produces this marked 
deformity of the forehead. 

The forehead looks high and square, and the top of the head is usually 
depressed. This condition of the bones may be only temporary, but if 
there is much deposit under the periosteum it will sometimes remain, and 

Case 512. 





Rhachitic head. Male, 3 years old. 



where calcification takes place quickly the thickened areas of the bone will 
remain unabsorbed throughout life. These areas of thickening, however, are 
often absorbed. 

The teeth in rhachitic children are late in developing, and the intervals 
between the appearance of the different groups are longer than normal. 
The lower jaw is apt to be short and its angle sharp and prominent. 

This infant (Case 512) shows the square rhachitic head. 



UNCLASSIFIED DISEASES. 1069 

In striking contrast to the large square head is the narrowed and 
flattened thorax. There is usually a compression of the chest laterally and 
a protrusion of the sternum and lower ribs, due to a constriction following 
the line of the diaphragm. The costal cartilages are frequently enlarged at 
the junction with the ribs, and can be felt and often seen as a line of 
rounded prominences. These prominences are called the rhachitic rosary. 
This rosary, although most commonly occurring in the latter part of the 
first year, has been noticed by Jacobi at the age of two months, and it has 
also been met with in the early weeks of life. The sternum may be de- 
pressed, or with the costal cartilages it may be pushed forward, forming 
what is known as pectus carinatum (pigeon-breast). 

Fig. 150. 




Inner surface of sternum, with cartilages and portions of ribs attached, showing rhachitic rosary. 

Here is a specimen (Fig. 150), taken from a rhachitic child, of the 
sternum to which are attached the cartilages and portions of the ribs. 

It shows on the inner surface a distinct rosary. During life this rosary 
could not be detected on the outer surface of the thorax. 

This infant (Case 513, page 1070) shows very markedly a rhachitic 
rosary, with depression of the lower part of the thorax, and enlarged 
epiphyses at the wrist. 

I have described in previous lectures (pages 71, 1019, 1045) the various 
deformities of the sternum which arise in connection with a delay in ossi- 
fication, and which may also occur in such defective ossification as takes 
place in rhachitis. In addition to these anterior and lateral deformities of 
the thorax, kyphosis is quite frequently seen in cases of rliaehitis at the 
junction of the lumbar spines when the children begin to stand erect and 
to walk. Lordosis may be present. Lateral curvature may also occur. 



1070 



PEDIATRICS. 



This child (Case 514) shows rhachitic kyphosis to a marked degree. 
I shall not attempt to describe all the deformities which may arise in 
rhachitic bones. They are very numerous, and, although exceedingly inter- 



Case 513. 




Rhachitic rosary and enlarged epiphysis of the wrist. Female, 25 months old, 

esting and important, are in the province of the orthopaedic surgeon rather 
than in that of the physician. A well-marked deformity in connection with 
the limbs is the enlargement of the epiphyses, which I have just described 

Case 514. 




Rhachitic kyphosis. Female, 3 years old. 

when showing you this bone (Fig. 149, page 1067). These enlargements 
are especially noticeable at the wrists and ankles. The legs are apt to be 
bowed. Knock-knee is also often a result of rhachitis. 

This child (Case 515, page 1071) shows a number of rhachitic de- 
formities. 



She has a square head. The thorax is narrow and contracted, 
nent. The epiphyses of the ankles and wrists are much enlarged. 



The sternum is promi- 
The arms are bowed. 



UNCLASSIFIED DISEASES. 



1071 



Slight lateral curvature is present. The ahdomen is distended. She is bow-legged and 
knock-kneed, and has flat-foot. 

Here is another child (Case 516) who shows markedly the rhachitic 
deformities of the wrists, the distended abdomen, the rosary, and the 
rhachitic head. 



Case 515. 



Case 516. 





Ehachitic deformities. 



Rhachitic deformities. Male, 2 years old. 
The enlarged epiphyses of the ribs are marked 
•with black spots. 



Congenital Rhachitis. — Although the occurrence of intra-uterine 
rhachitis has been disputed, yet there seems to be sufficient eyidence of such 
a disease in new-born infants to warrant the statement that rhachitis may 
be met with in this early stage of existence : it is, however, a very rare 
affection. I have seen a case of congenital rhachitis in which the rhachitic 
process had run its course and the hardening of the bones had apparently 
been completed before the infant was born. 

Another case of congenital rhachitis which has come under my obser- 
vation was seen by me in consultation with Dr. Townsend (Case 517, page 
1072). The parents were young and healthy, and there was no history of 
syphilis or rhachitis. The father was American, the mother Scotch. There 
was one other child, three years old, strong and well. The mother during her 
pregnancy was much worried, and her nourishment was both insufficient and 
poor. The infant, a male, was one month premature. The lalx)r was easy. 
The infant weighed seven pounds and was 43.3 cm. (17 inches) in length. 

I have here a photograph which was taken on the fourth day of the 



1072 



PEDIATRICS. 



infant's life. The head, as you see, was square in front, was much flat- 
tened behind, and measured 33.8 cm. (13 J inches). The sutures were all 
widely open. The ossified portions of all the bones of the skull were 
small, particularly of the occipital bone, which presented a large area of 
craniotabes. In the widely-opened sagittal suture just back of the anterior 

Case 517. 




Congenital rhachitis. 

fontanel le was a large Wormian bone 2.7 cm. (1 inch) long. In the 
squamous and coronal sutures on the right side at least eight small Wor- 
mian bones could easily be felt, and on the left side eleven were counted. 
The thorax was 30 cm. (llf inches) in circumference, and was depressed 
laterally, the depression increasing with each inspiration, owing to an accom- 
panying atelectasis in the lower portions of the lungs. There was consider- 
able cyanosis. No cardiac murmur was detected. A rhachitic rosary was 
present. The abdomen measured at the level of the umbilicus 28.7 cm. 
(11 J inches). There was a large double inguinal hernia. The spleen could 
not be detected on examination. The liver could be felt below the edge of 
the ribs, but was apparently not enlarged. There were marked enlargement 
of all the epiphyses, curvature of all the long bones, and numerous fractures. 
The humeri showed a slight anterior curvature. The bones of each forearm 
were also bent anteriorly. The femora were curved outward and forward. 
The lower legs showed marked angular curvatures forward at the junction 
of the middle and lower thirds. The fractures were apparently of as recent 
origin as the birth, as some of them proceeded to unite very quickly. On 
the eighth day the fracture of the right tibia was quite firmly united ; and 
only a slight crepitus could still be felt over the left tibia. The fracture 
of the left humerus was firmly united with a ring of callus. The right 
humerus at birth showed a callus about the middle of the shaft : this was 
evidently the repair of an intra-uterine fracture. The child died on the 
ninth day of its life. 



UNCLASSIFIED DISEASES. 1073 

Symptoms. — The symptoms of rhachitis are those of a slowly develop- 
ing constitutional disease. The early symptoms are those which may occur 
in a number of diseases, and are closely connected with disturbance of the 
gastro-enteric tract. The children, although they are often quite heavy, 
are anaemic, and their muscles are soft. The increase in weight depends 
more on the increase of fat, the normal relative proportion between fat and 
muscle being altered. Their appetite is capricious ; they become fretful, and 
perspire at night, especially about their heads. They do not learn to Avalk 
so early as does the normally developed infant, and they soon show the later 
and more characteristic signs of rhachitis. I have already spoken of these 
signs when describing the pathology of rhachitis. As a rule, however, the 
picture of a rhachitic child is one with a square, prominent forehead, and 
with an anterior fontanelle remaining open after the age of eighteen months ; 
dentition is delayed ; the thorax is narrow and compressed laterally ; the 
rhachitic rosary and enlargement of the epiphyses of the wrists and ankles 
are present, and the abdomen is distended. The bones of the extremities 
may be bowed, and the feet may be flat. In some cases there is considerable 
tenderness of the bones and muscles. The muscles are often so weakened 
by the depressing effects of the disease that the child has not sufficient 
strength to walk steadily. There are also a series of nervous phenomena 
connected with rhachitis which play a very prominent part in the disease. 
Convulsive attacks are more frequent in rhachitic children than in those 
whose nervous system is in equilibrium. The condition of laryngospasmus, 
which I have described to you in previous lectiu-es (pages 747, 949), is at 
times a prominent feature in the symptoms of rhachitis. Khachitic children 
are more liable to die than other children when attacked with such diseases 
as pneumonia or bronchitis. Attacks of the acute exanthemata are of 
serious import in rhachitic children, and these children are especially liable 
to the invasion of the bacillus tuberculosis. 

Diagnosis. — The diagnosis of rhachitis should be made from a num- 
ber of diseases in which the general nutrition of the child is profouudly 
disturbed. When the disease is fully developed the diagnosis is not diffi- 
cult. In its early stages, however, the manifestations of rliachitis may be 
so slight that the diagnosis must often be kept in abeyance. I have already 
spoken of the diagnosis of rhachitis from hereditary syphilis, and, as a rule, 
no difficulty arises. You must remember that syphilis and rhachitis have 
no direct connection with each other, but are both chronic constitutional 
diseases, and that it is possible to have both diseases occur in the same indi- 
vidual. I have described the syphilitic bone in a previous lecture (page 
497). AVhen there is enlargement of the long bones it is not limited to 
the epiphyses, as in rhachitis, but involves the ends of the diaphysis. It 
is often accompanied by a condition which closely simulates a callus, and 
there is a distinct tendency to fracture in syphilis rather than to the 
bendinar which is common in rhachitis. The notched teeth and the cranio- 
tabes may occur in both diseases, while the lesions of the mouth and 

68 



1074 PEDIATRICS. 

lips, which I have already fully described (page 494), are distinctive of 
syphilis. 

The diagnosis from scorbutus I shall speak of presently (page 1077). 

The heightened temperature and the acute tenderness and swelling of 
the joints in acute articular rheumatism are easily distinguished from the 
subacute or chronic course and the characteristic enlargement of the epiph- 
yses in rhachitis. 

Rhachitis, where it causes kyphosis of the spine, may simulate Pott's 
disease very closely. It occurs at the dorso-lumbar junction, which is a 
frequent seat of the deformity in Pott's disease. The spine is held rigidly 
in severe cases, just as in Pott's disease, and the deformity may be angular 
rather than the usual gradual curve. The coexistence of enlarged epiphyses 
and other rhachitic conditions makes it very probable that the affection is 
rhachitic ; but both diseases may coexist. 

In general, the age of the child, the absence of much pain, and the 
existence of other signs establish the diagnosis of rhachitis. It is, more- 
over, in children under two, much more common than Pott's disease. In 
doubtful cases the diagnosis can be made only after several examinations 
and a period of two or three weeks of recumbency, under which conditions 
the rhachitic spine becomes somewhat more flexible. 

Cases of rhachitis which do not walk until late, on account either of 
muscular weakness or of tenderness, may resemble cases of organic nervous 
disease with true paralysis. The diagnosis must rest on the presence of the 
general signs of these nervous diseases already described. 

The existence of flat-foot in children over two years old should lead to 
an examination for knock- knee. The combination of these two conditions 
will in most cases be found to be dependent upon present or previously 
existing rhachitis. 

Prognosis. — The prognosis of rhachitis is favorable, provided no com- 
plications arise. A spontaneous arrest of the disease may take place in 
any of its stages, but, as a rule, if the affection is at all pronounced, serious 
deformities are usually produced. If a hydrocephalic condition, which at 
times appears in rhachitis, is present to any degree, if there is much diar- 
rhoea, or if the infant is subject to frequent attacks of bronchitis, the prog- 
nosis is very unfavorable. 

When properly treated, the health of these children improves slowly, 
and, unless the deformities which have occurred in the bones have advanced 
too far, more or less complete recovery usually takes place in the third or 
fourth year. 

Treatment. — The treatment of rhachitis is essentially dietetic and 
hygienic. The infants should be kept in the open air as much as possible, 
and should live in rooms accessible to sunlight. The food should be adapted 
to the age, according to the rules which I have given for the feeding of 
normal infants during the first two years of life. There does not appear to 
be any drug which produces a specific effect upon the osseous changes which 



Case 518 Fig, 151. 

.ill :<'.ii£-<fs^^^, ,, 




Vertical section of leg in a case of infantile scorlnitns. The red areas anmn.l the femur and tilua 
represent subperiosteal hemorrhages. ^Specimen preserved in the Museum of the tVvllegeof I'hysi- 
eians and Surgeons, New York.) 



UNCLASSIFIED DISEASES. 1075 

take place in rhachitis. Phosphorus is considered by some observers to be 
a valuable adjunct to the general dietetic and hygienic treatment, but, 
according to our experience at the Children's Hospital, it has not proved 
to be of any especial benefit. 

Where the anaemia is marked, iron in some form should be given, and 
at times an increase in the fat in the food seems to be beneficial. 

There has been much discussion as to whether a form of acute rhachitis 
exists apart from the disease scorbutus, which is now well recognized as 
occurring in young infants. There are certain cases of rhachitis in which 
the disease is in the beginning more pronounced and more acute in its 
development than usual. Again, in the course of an ordinary case of rha- 
chitis acute symptoms may arise. But cases presenting the symptoms to 
be described under the heading of scorbutus should not be considered neces- 
sarily as acute forms of rhachitis on account of the severity of the symp- 
toms, but for the present should be classed as scorbutus supervening on 
rhachitis. 

Scorbutus (Scurvy). — Scorbutus is a constitutional disease closely as- 
sociated with imperfect nutrition and having a definite relation to the 
deprivation of the individual from fresh food. It is characterized by 
ansemia and a tendency to hemorrhage, and in most cases is accompanied 
by the condition of the gums which is present in stomatitis ulcerosa. 

Etiology. — In addition to the view^ that the cause of scorbutus is 
of chemical origin, owing to the significant relation which the disease has 
to a lack of fresh food, it is supposed that there may be a special micro- 
organism which causes the disease. This, however, has not been proved, 
and we have no further knowledge regarding the etiology of scorbutus. 

Pathology. — So few post-mortem examinations have as yet been made 
on infants dying of scorbutus that the pathological lesions have not been 
finally established. A sufiicient number of autopsies, however, has been 
reported by Barlow and others, notably Northrup, to settle at least the more 
important features in the pathology of infantile scorbutus. 

There are no alterations in the blood, either anatomical, chemical, or 
bacteriological, which can be considered peculiar to scorbutus. There are 
deep hemorrhages into the muscles and occasionally about or even into the 
joints, but the hemorrhage in infantile scorbutus is essentially subperiosteal 
and chiefly of the long bones. The femora are most commonly aifected, 
and there is a tendency to separation of the epiphyses. There may also 
be a varying amount of interstitial hemorrhage in the lungs, spleen, 
kidney, and intestinal glands. Hemorrhages into the mucous surfaces are 
usually present, the gums being chiefly aflected and presenting the condition 
of stomatitis ulcerosa, which I have described in a previous lecture (page 
781). 

By permission of Dr. Northrup, I have had a section made of the bones 
of the leg of an infant (Case 518, Fig. 151) who died of scorbutus, under 
his care. 



1076 



PEDIATRICS. 



On examining this specimen you will see that the femur is normal at its upper ex- 
tremity. The lower half is invested with a black, grumous, subperiosteal layer of blood. 
The lower epiphysis is detached, and the lower end of the shaft, macerated, eroded, and soft, 
is lying loose in the black, disintegrating blood-clot. The tibia is surrounded by thin, dark, 
hemorrhagic layers beneath the periosteum, and the proximal portions are congested. The 
fibulae and the bones of the upper extremities were normal. 

Here is a microscopic section (Fig. 152, Case 519j of this bone, which shows no syphi- 
litic or rhachitic changes in the bone or the periosteum. 

Case 519. Fig. 152. 




Section of scorbutic bone. Med., medulla ; B., bone ; Hem., hemorrhage ; Per., periosteum. 

The soft macerated bone gave no evidence of suppuration, but there was a moderate 
congestion of the femur and the upper extremity of the tibia. 



Symptoms. — The symptoms of infantile scorbutus are those of a slow 
and progressive cachexia. The infants become ansemic, and show more or 
less gastro-enteric disturbance of a subacute functional type. Profuse sweat- 
ing, especially about the head, at times slight feverish attacks, and lessened 
appetite, are among the early symptoms. The temperature may be from 
time to time slightly raised, but not significantly so. The first symptom, 
however, which especially attracts the attention is a sensitive condition of 
the bones. The infant cries when the affected parts are touched. It does 
not seem to suffer pain when it is allowed to remain quiet, but as the disease 
advances the expression of its face indicates the fear of being handled. My 
individual experience with infantile scorbutus has been derived from sixty 
or seventy cases, all of which, with few exceptions, were from eight to twelve 
months of age. I have met with no cases later than the first half of the 
second year, and with none earlier than the first half of the first year. 

As the disease progresses, more marked symptoms develop. Swellings 
of the limbs, usually of the diaphyses just above the epiphyses, appear. 



UNCLASSIFIED DISEASES. 1077 

These swellings are most common" and most prominent in the legs, but 
may also appear in the bones of the forearm. They are usually pyriform 
and symmetrical in shape, the skin over the swelling being more or less 
tense, but not fluctuating. There is commonly some tenderness on pressure, 
but, as a rule, no especial heat of the affected part. The pain and swelling 
do not seem to be in the joint, but in the diaphysis and epiphysis. Signs 
of hemorrhage may occur in the skin over the affected parts, appearing at 
first as small blue maculae and later involving larger areas, as though a 
deep hemorrhage were coming to the surface. In advanced cases hemor- 
rhage may take place to such an extent in the deeper parts around the eyes 
that the eyes will be pushed forward (proptosis). 

Where the infant has not cut any teeth, the mucous membrane of the 
gums, according to my experience, has not been affected ; but where a tooth 
is pressing on the gum and is almost through, or even where a small portion 
of a tooth has penetrated the gum, small areas of congested mucous mem- 
brane appear, and are of great aid in the diagnosis. In some cases a few 
hemorrhagic maculae appear in other parts of the skin, as of the forehead. 

In addition to the symptoms of epiphyseal pain, the infant keeps the 
affected limb perfectly still, so that, unless it were understood that it is pain 
which prevents it from moving the limb, it might be supposed that it was 
paralysis ; in fact, this symptom in scorbutus has been termed pseudo- 
paralysis. It has, of course, nothing to do with true paralysis, and corre- 
sponds to what is seen in rheumatic affections of the joints. 

Diagnosis. — The diagnosis of infantile scorbutus is to be made from 
rheumatism, rhachitis, purpura, syphilis, and spinal paralysis. 

In the diagnosis from rheumatism the absence of heat and tenderness 
of the joint and of a pronounced rise of temperature is usually sufficient 
to distinguish the two diseases. 

The diagnosis from rhachitis is to be made by the presence of hemor- 
rhages, the intense pain in the region above the epiphyses, the absence of a 
rhachitic rosary, and the absence of symptoms of rhachitis when it is not 
coexistent. If teeth are present, the occurrence of stomatitis ulcerosa 
usually makes the diagnosis clear. Out of all my cases there have been 
only a small number, perhaps a dozen, that have shown any symptoms 
whatever of rhachitis. In these cases where rhachitis was present the symp- 
toms of scorbutus appeared to complicate a primary rhachitis, and when the 
scorbutic symptoms passed away the rhachitic manifestations remained. 

Purpura, except in the severe forms in which the joints are affected, is 
easily differentiated by the absence of the peculiar osseous symptoms of 
scorbutus. 

Scorbutus is differentiated from syphilis by the extreme tenderness, the 
hemorrhages, and the commonly occurring stomatitis ulcerosa which occur 
in the former disease, while syphilis has distinctive symptoms which are 
not found in scorbutus, and which I have already described (page 491). 

The differential diagnosis between scorbutus and spinal paralysis is made 



1078 PEDIATRICS. 

by the presence in the former of enlargement and tenderness in the neigh- 
borhood of the epiphyses. Pain is present only in the initial stage of spinal 
paralysis, and tenderness is absent. In spinal paralysis, also, the onset is 
sudden, and there are no premonitory symptoms. 

Prognosis. — Scorbutus is very variable in its duration. If left un- 
treated, all the symptoms may become more pronounced and the infant 
finally die of exhaustion. When properly treated, and uncomplicated by 
any other disease, the prognosis is very favorable if treatment is begun early 
in the attack, before the vitality of the infant has been too much reduced. 

Treatment. — The treatment of infantile scorbutus is essentially by 
changing the improper food which in most cases is being given, to fresh 
milk and orange juice. Under this treatment the pain and tenderness of 
the limbs rapidly disappear, sometimes within a few days, as does also 
the stomatitis ulcerosa. In the beginning the juice of one orange should 
be given in the twenty-four hours. If a rapid improvement does not take 
place, a still larger dose should be given within a few days. These scorbutic 
infants usually take orange juice with avidity, but they should be forced 
to take it if they do not like it. The nurse should be cautioned to move 
the affected limbs as little as possible, and the infant should be kept on a 
comfortable pillow on which it can be carried about. 

In my earlier cases, before I recognized the scorbutic element in the 
disease, I treated these infants with a number of drugs, none of which 
appeared to have the slightest beneficial effect. In some of these cases 
the symptoms grew progressively worse, and the infants died. In one of 
them, however, where the hemorrhages in the skin were extensive and 
where proptosis was marked, the infant recovered entirely when a properly 
modified fresh milk was substituted for the artificial food which it had been 
taking. In some of the later cases which I have seen in consultation, 
where infants living in the country with good hygienic surroundings were 
being fed on one of the many artificial foods, the disease had progressed to 
such an extent that the infants were extremely anaemic, had hemorrhages 
in various parts of the skin, were unable to take any food, and were seem- 
ingly dying ; in fact, they were as much reduced as were the cases which I 
have just spoken of as having terminated fatally. These infants, after 
taking orange juice for a few days, invariably improved rapidly, and usually 
recovered entirely in two or three weeks. 

In my experience there is no evidence that sterilized milk is a cause of 
scorbutus. If the milk is properly modified it can be heated to 75° C. 
(167° F.), or even to 100° C. (212° F.), without, so far as I am aware, 
having a deleterious effect upon the osseous system. 

All my cases have presented in different degrees the symptoms which I 
have just described, and which are well represented in this infant whom I 
have here to show you to-day. 

This infant, a female (Case 520), ten months old, was healthy at birth and weighed 
3636 grammes (8 pounds). It was nursed at first, but later was fed on a patent food, on 



TJIs^CLASSIFIED DISEASES. 



1079 



which it did not gain. "When it was eight months old it lost somewhat in weight, had pro- 
fuse sweating, and began to have tenderness in its limbs. It has six teeth. On looking at 
the infant you see an expression of fear on its face, and also that it keeps its arms and legs 
perfectly motionless. 

Case 520. 
I. 




Infantile scorbutus. (Second month of disease.) Female, 10 months old. 

Whenever it thinks that I am about to touch the legs or the arms it cries with fear. 
There is no evidence of rhachitis in this infant. You see that there is a swelling of the 
diaphysis just above the epiphysis of the bones of the right wrist, and also in the lower part 
of the femur of each leg and the lower part of the tibia. The swelling does not fluctuate, 
has a hard, tense feeling, and apparently is not connected with the joints. There is no 
increased heat of the skin, but there are certain circumscribed areas of hemorrhage in the 
skin over the swellings. The gums show the condition of stomatitis ulcerosa to so marked 
a degree that they almost cover the teeth. They are purple, bleed easily, and are very 
similar to those seen in the case of scorbutus which I showed you at an earlier lecture 
(Plate YIII., Scorbutus, facing page 781). 




Infantile scorbutus. (One month after treatment. ) Female, 10 months old. 

(Subsequent history.) The infants diet was changed to a modified milk, and it was 
given the juice of one orange daily. Within two days it moved its legs and arms freely, 
the anxious expression left its foce, and in a few weeks it had gained much in weight and 
was perfectly well (II.). 

There was no evidence of rhachitis. 



An examination of the blood in this case orave the followino: rcsnlt 



1080 PEDIATRICS. 

BLOOD EXAMINATION 38. 

Eed corpuscles 4,435,000 

Haemoglobin 35 per cent. 

White corpuscles : 

Small mononuclear 8 " 

Large mononuclear . 44 " 

Polynuclear leucocytes 57 " 

Eosinophiles 1 " 

The blood examinations in two other cases gave the following results : 

BLOOD EXAMINATION 39. 

Ked corpuscles 4,660,000 

Haemoglobin . . 45 per cent. 

White corpuscles : 

Small mononuclear 5 " 

Large mononuclear 73 " 

Polynuclear leucocytes 22 " 

BLOOD EXAMINATION 40. 

Ked corpuscles 4,602,500 

Haemoglobin (not obtained) 

White corpuscles : 

Small mononuclear 10 per cent. 

Large mononuclear 68 " 

Polynuclear leucocytes 21 " 

Eosinophiles 2 " 

RHEUMATISM. — Rheumatism is a non-contagious febrile disease, when 
aifecting children usually subacute, and characterized by pain sometimes in 
the joints and sometimes in the muscles. 

Etiology. — The cause of rheumatism is not known, although that the 
disease is incited by exposure to cold and dampness is evident. It is pos- 
sible that it is microbic in its origin, this view being strongly supported by 
the intimate relation between rheumatism and endocarditis, since the latter 
disease has been proved to be of bacterial origin. Acute articular rheuma- 
tism is rare in early life, though it may occur at any age. Subacute attacks 
of rheumatism, characterized by pains in various parts of the body and 
limbs and a moderate heightening of the temperature, are very common in 
childhood. The more severe forms of rheumatism which occur in adults, 
such as arthritis deformans, are very rare in children. The chronic form 
of rheumatism is also rare in early life. The chief characteristics of rheu- 
matism in young children are that often it does not involve the joints, and 
that the milder forms of the disease are much more apt to be complicated 
by endocarditis than is the case in adult life. 

Pathology. — There are no lesions which especially characterize the 
pathology of rheumatism. The lesions which occur in the course of the 
disease are those of other diseases, such as endocarditis or pericarditis, which 
so frequently complicate it. Small subcutaneous fibrous tumors at times 
appear during an attack of rheumatism, especially in children, and may be 



UNCLASSIFIED DISEASES. 1081 

found in any part of the body or limbs. They seem to be closely connected 
with rheumatism, and the cases in which they occur are frequently associated 
with endocarditis. 

Symptoms. — The symptoms of rheumatism when uncomplicated vary 
according as the disease is the acute articular form or locally atfects the mus- 
cles of various parts of the body, such as the neck (torticollis) ; sometimes 
the disease is simply represented by indefinite pains, v/hich may last f3r a 
number of days and then disappear to recur at a later period. The symp- 
toms are, as a rule, not so severe as in later life, even when the joints are 
affected, and in the few cases of articular rheumatism in children which have 
come under my care the suffering has been very slight in comparison with 
what is experienced in adults. In the acute articular form there are swell- 
ing, tenderness, and redness of one or more joints, accompanied by a height- 
ened temperature and loss of appetite. A very common accompaniment 
of rheumatism is anaemia. The disease runs a varying course of three to 
six weeks, unless complicated by some other disease. The most coramon 
complications are endocarditis and pericarditis, and when these diseases ap- 
pear the symptoms of these complications become prominent. In some 
cases the endocarditis may appear before the development of the rheumatic 
symptoms. 

Peognosis. — The prognosis of rheumatism in children is very favorable, 
unless complications arise, in which case it depends upon the severit\^ of 
the complication. 

Treatment. — Rheumatism in the articular form is a self-limited dis- 
ease, and the treatment is purely symptomatic. The child should be kept 
in bed in a room of an equable temperature, 20° to 21.1° C. (68° to 70° 
F.). The affected joints should be wrapped in cotton wool. No applica- 
tions to the joints are, as a rule, indicated. For the alleviation of the pain 
salicylate of sodium in moderate doses according to the age of the child is 
valuable ; but there is no drug which is in any sense curative of rheuma- 
tism, and salicylate of sodium has not been found to lessen the frequency 
of cardiac complications. The oil of gaultheriiun can also be used, and has 
about the same efficacy as salicylate of sodium. Opiates are seldom needed. 
A careful physical examination should be made every day in these cases of 
rheumatism, in order to detect the cardiac complications which are so likely 
to arise. During the acute stage of the attack the diet should be broths and 
milk. A number of careful observers believe that an alkali, such as citrate 
of potassium, should be given in conjunction with the salicylate of sodium. 

I have some cases here in the wards which illustrate the different forms 
of rheumatism in children. 

Here is a boy (Case 521, page 1082), three years and four months old, who has been 
treated in the hospital for bronchitis, and when he was convalescent from that disease was 
attacked with acute articular rheumatism. 

There is no rheumatic history in his fomily, and he has never had rheumatism nor any 
other disease except the bronchitis for which he was admitted to the hospital. After having 



1082 



PEDIATRICS. 



been feverish for two days, the temperature varying from 37.7° to 38.8° C. (100° to 102° 
P.), he complained of pain and tenderness in his shoulders, wrists, and elbows. On the 
following day these symptoms increased, being especially marked in the left hand and left 
knee. You see the expression of anxiety on his face, showing that he fears that the tender 
joints will be touched. The weight of the bedclothes is kept from the knee by this cradle, 

Case 521. 







Acute articular rheumatism. Adult type of disease. Male, 33^ years old. 

and the arm is comfortably arranged on a pillow. These details in the nursing of a rheu- 
matic child are very important. The cotton wool has been removed from the joints, that 
you may see how swollen and reddened they are. He is being treated with oil of gaul- 
therium, 4 minims every three hours. The temperature has risen to-day to 39.7° C. (103.5° 
P.). An examination of the cardiac region does not detect any cardiac complication. 

(Subsequent history.) The child sutfered considerably for four weeks, but at the end 
of that time the joints gradually grew less painful, and he was entirely well thirty-three 
days from the onset of the attack. 

CHAET 48. 





Days of Disease. 




IF. 


1 


2 


3 


4 


5 


6 


7 


8 


9 


10 


11 


12 


13 


14 


15 


16 


17 


c. 


107 
106 
105 
104 
103 
102 
101 
100 
99 

>IORM'l 
TEMP. 

98 

97 

96 
95 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


ME 


M E 


M E 


M E 


M E 


M E 


M E 


ME 


41.6" 

41.1° 
40.5° 
40.0° 
39.4° 
38.8° 

38.3° 

31.1 

37.2° 
37.0° 
36.6° 

36.1° 

35 5° 
















































































































/ 






























/] 




/ 
































\ 


/ 


/ 


/ 


/ 


^ 








A 


/ 










/^ 




\ 






/ 




^ 








/ 


/ 


























\ 










y 


A 




y 






















._-. 








/ 


^ 








































































































































35.0° 



Acute articular rheumatism. 

Here is a chart (Chart 48) which shows the range of his temperature for the first 
seventeen days. 



UNCLASSIFIED DISEASES. 



1083 



This next child, a girl (Case 522), five and one-half years old, is interesting as illus- 
trating a number of characteristics in connection with the rheumatism of children. 

CHAKT 49. 





Days of Disease. 




F. 


4 


5 


6 


7 


8 


9 


10 


11 


12 


13 


14 


15 


16 


c. 


107° 

loe" 

105° 


M E 


M E 


M E 


M E 


RI E 


U E 


ai E 


M E 


M E 


M E 


M E 


M E 


M E 


41.6° 
41.1° 
40 5^^ 


































. 
























1 






















103 


/ 




1 




















39 4° 


102° 

101 

100° 

99 

NORM'U 
TEMP. 

98° 
97° 

96° 

95 


J 




1 




















38.8° 

38.3° 

37.7° 

37.2° 
37.0° 
36.6° 

36.1° 

35.5° 

35.0° 








N. 




















\ 




N 


A 




















>^ 


1/ 






^ 








/ 


^ 













— - 


— 


— ■ 


^ 


/ 


l:_. 


<- 




^ 


.... 
















































































150 

140 

130 

120 

110 

100 

90 

80 

70 

60 




























i 
I 


1 




\, 






















/ 


























/ 






S 




















-i 




































/ 








/ 


















/ 






/ 


/ 


/ 




















J 


/ 




/ 


^ 


















A 


^ 








U- 




























50 
45 
40 
35 
30 
25 
20 
15 
10 




























o 






















































A 




\ 




























^ 






















\ 






/ 


A 


/ 


/ 


y 


^ 
































i 

















































































Acute articular rheumatism. Acute endocarditis on seventh day from l>c£rinninjr of attack. 



She was attacked eight days ago with pain, swelling, and tenderness in her loft ankle. 
On entering the hospital her temperature was 40° C. (104° F.), her pulse was 145, and her 



1084 



PEDIATRICS. 



respirations were 40. There was very slight pain in the joints, and, although her appetite 
was lessened, she otherwise seemed well, and she has not complained of any pain since the 
beginning of the attack. On the sixth day the temperature fell to 37.2° C. (99° F.). It 
has' been interesting to note the extreme latency of the disease, and how the child has 
seemed to be perfectly comfortable from the beginning of the attack, except when the 
ankles, both of which are swollen and tender, were touched. Yesterday, the seventh day 
of the disease, the temperature rose to 38.6° C. (101.5° F.), and an examination of the 
chest showed a mitral systolic murmur. To-day the murmur is more marked, and is 
transmitted to the axilla and the back. The area of absolute cardiac dulness is slightly 
increased, and extends to the middle of the sternum. 

(Subsequent history.) By the end of the second week of the attack the pain and 
tenderness had left the ankles, and the child seemed quite well. The area of absolute dul- 
ness was found to be normal, but the systolic murmur still continued. 

The chart (Chart 49, page 1083) shows the rheumatism gradually subsiding up to the 
seventh day of the disease, when the endocarditis arose as a complication. 

I have here a boy (Case 523) who during an attack of rheumatism developed the sub- 
cutaneous fibrous nodules which I have just described. 

Case 523. 





Rheumatism. Subcutaneoiis fibrous nodules. Male, 13 years old. 



When he was seven years old he had an attack of rheumatism affecting his ankles and 
the muscles of his neck. His temperature was 37.2° C. (99° F.) ; his urine was normal. 
During this attack a systolic souffle transmitted to the axilla developed, and the area of 




Acute rheumatic torticollis. Fifth day of attack. 




Acute rheumatic torticollis. Sixth day from l)ei,duning of attack. Recovery. Ni: 



UNCLASSIFIED DISEASES. 1085 

absolute cardiac dulness was increased. This attack lasted eight days. He is now thirteen 
years old, and ever since his rheumatic attack, six years ago, he has had more or less 
dyspncea on exertion, and at times cardiac pain, but he has never had any marked return 
of the rheumatism. He has lately noticed these small lumps appearing under his skin. 
When they were first noticed he had indefinite pains in his limbs, severe headache, and 
malaise. Some of the lumps are slightly tender. You see that they are on the chest, arms, 
abdomen, and legs, mostly on the anterior surface. 

I have here an interesting case of the acute localized form of rheumatism 
which sometimes occurs in children. 

This boy (Case 524) is five years old. Since he was three years old he has been subject 
to attacks of torticollis, apparently of rheumatic origin. Five days ago he was brought 
into the hospital in one of these attacks. His temperature is somewhat raised, and he has 
a slight loss of appetite, but otherwise he is perfectly well, and he does not sutler any pain 
except when his neck is touched. The head, as you see, is drawn rigidly back. These 
paroxysmal attacks usually last two or three days, when they pass off as suddenly as they 
came. The last attack which he had was one year ago. 

(Subsequent history.) On the following day the stiffness and the pain in the neck 
passed off, and the head resumed its normal position. 

Various drugs have been given in these attacks, but none with any especial benefit 
except salicylate of sodium, which seems to control the pain. 

I have also had under my care a little boy (Case 525), about four years of age, who 
was attacked with fever, pain in the region of the spine, and spasm along the entire length 
of the spinal column. There was no pain or tenderness anywhere except over the ver- 
tebral column, and these symptoms were not so marked in the cervical region as lower 
down. The child had no mental disturbance, but for a number of days was in a condition 
of continued opisthotonos from the hips upward, and he had to be kept in a reclining chair 
with pillows under his arched back. The normal functions of the bladder and intestine 
were not interfered with. The pulse was quick, the temperature was moderately raised, 
and the respirations were normal. The appetite was lessened. 

He reniained in this condition for about a week, when the spasm of the back began to 
disappear. The muscles relaxed for a short time and then stiffened again. Finally com- 
plete relaxation took place, and the child recovered entirely. 

The attack was acute in its onset, and did not follow any injury. The treatment was 
with bromide of potassium, 0.3 gramme (5 grains) three or four times in the twenty-four 
hours. 

It seems to me that this case can be classed as one of spasmodic rheumatism. 

Although acute articular rheumatism is rare in infancy, I have met 
with a number of cases at this early period of life. 

I have already referred to the little girl (Case 41, page 127), two years 
old, who, after exposure, was attacked with acute rheumatism in both hip- 
joints. 

I have also met with a case of general acute rheumatism attacking all the joints, in an 
infant (Case 526) two weeks old, after exposure to a cold draught while being bathed. Any 
movement of the joints caused the infant to scream. He lost rapidly in weight, his surface 
circulation was disturbed, and the attack lasted for four months; but when he was six 
months old he was perfectly well, and no cardiac complication developed during the attack. 

Another case of this kind was an infant (Case 527) who was attacked with general 
acute rheumatism when she was seven months old, the attack histiiig until she was fifteen 
months old, when she recovered without any cardiac complication, and who is a well, strong 
child to-day. 



1086 PEDIATRICS. 

Cases of this kind must^ of course, be differentiated from scorbutus, 
which sometimes closely simulates rheumatism, and of the diagnosis of 
which I have already spoken. 

Acute Arthritis of Infants. — A disease usually confined to one 
joint, probably starting as an acute infection of the epiphysis, and followed 
by an effusion into the joint which rapidly becomes purulent, has been called 
the acute arthritis of infants, and must be distinguished from rheumatism. 
The disease is essentially surgical in its nature. 

The symptoms which would lead you to suspect that a more serious 
affection than rheumatism had attacked the infant are not definite, but are 
somewhat as follows. The disease occurs only under two years of age, 
and usually in the first year. The onset is sudden. There are a heightened 
temperature and intense pain, sometimes in a number of joints, but usually 
localized in one joint, and accompanied by symptoms of a character grave 
beyond what would be expected in rheumatism. As in rheumatism, the 
part affected is swollen, reddened, tender, and fixed, but the surrounding 
soft parts are also involved to a greater degree than when the attack is of 
rheumatic origin, and the swelling, at first tense, soon grows fluctuating as 
the joint becomes involved. From the beginning of the disease the signs 
of sepsis, as shown by great prostration, rapidly supervene. 

The prognosis is very unfavorable, unless immediate and radical surgical 
treatment is carried out ; but a number of cases have been cured. 

The case should be placed at once in the hands of a surgeon. The treat- 
ment should be immediate and free incision of the joint. 

PURPURA. — Purpura is a term applied to certain conditions in which 
there are hemorrhages into the skin or mucous membranes. These hemor- 
rhages may be of various sizes. When small, they are called petechise ; 
when larger, they are called ecchymoses. There is no proof that purpura is 
a disease of the blood. Its etiology is very obscure, and, although this con- 
dition has been divided into various forms, such as purpura simplex and 
purpura hsemorrhagica, it is doubtful whether these are not all microbic in 
their origin and simply represent different degrees of infection. 

In the more simple forms of purpura the hemorrhages are only in the 
skin, while in the more severe affection the mucous membranes of the mouth 
and gastro-enteric tract are usually involved. 

Not only does purpura occur in what may be called primary forms, 
but this purpuric condition may also be secondary to a number of diseases, 
especially those of an exhausting nature. Thus, I have seen it in the more 
severe and later stages of infantile atrophy, where the hemorrhages may 
cover almost the entire front of the body. It may also be a symptom 
in the more severe cases of measles, scarlet fever, varicella, variola, and 
diphtheria. 

In an infant (Case 528) who died of infantile atrophy at the Infants' Hospital the skin 
of the extremities showed numerous ecchymoses of various sizes and of a dark red and 
purple color. On the thorax on both sides above the nipples were two large ecchymoses, and 



UNCLASSIFIED DISEASES. 1087 

there were smaller ecchymoses all over the rest of the trunk. Or post-mortem examination 
nothing abnormal was found except a slight atelectasis of the lower lobes of both lungs, 
with pleuritic adhesions at the base of the right lung and slight granular degeneration of 
the heart, liver, and kidneys, with hyperplasia of the mesenteric lymph-glands. 

In the simple forms of purpura the disease in children is often mild, and 
is accompanied by a loss of appetite, slight anaemia, a slight degree of fever, 
and the appearance of petechiee in various parts of the skin. The prognosis 
is good, and the duration of these attacks is usually from one to two weeks. 
They are at times associated with pains located in various places. It is pos- 
sible for purpura to develop in the course of a rheumatic attack of great 
severity or where the infant's vitality is much reduced, just as it might 
appear in any prostrating disease. 

The form which has been called purpura rheumatica (peliosis rheu- 
matica ; Schonlein's disease) probably has no connection with rheumatism 
beyond the possibility of their both being microbic, and merely simulates 
rheumatic arthritis from the fact that it affects the joints. The diagnosis is 
made by the characteristic association of multiple arthritis with purpura 
and urticaria. Closely simulating and probably representing purpura 
rheumatica, except that the gastro-enteric symptoms are more prominent, 
is a form which has been called HenocNs purpura. It occurs especially in 
children between the ages of three and nine years. Its direct cause is not 
known, although it usually occurs among children who have bad hygienic 
surroundings and have been ill cared for. 

The symptoms are more or less malaise, and pains not especially local- 
ized, but chiefly occurring in the extremities and back, sometimes accom- 
panied by slight oedema of the part affected. These early symptoms of 
pain occur in one or more joints, usually on the outer sides, and sometimes 
there are swelling and redness simulating articular rheumatism. In this 
stage there may be a sudden rise of temperature. Accompanying these 
symptoms there may be a few purpuric spots, but, as a rule, there is a period 
of several days between the appearance of the pains in the joints and the 
purpuric appearances on the skin. The purpuric spots may coalesce, and 
thus form ecchymoses of various sizes and of various colors. They are 
very apt to begin on the lower leg and spread up to the thighs, genitals, 
and body. Somewhat later intestinal symptoms develop. While the 
purpura is spreading there is severe colic, and the pain is very intractable 
to treatment. The abdomen is retracted and tender. There is obstinate 
vomiting. The pulse is weak, and the face has an anxious expression. 
There is more or less diarrhoea, which usually occurs at the end of an 
attack of colic. The colic and vomiting sometimes last for one or two 
days. There may be a little blood in the vomitus and in the movements. 
The vomiting then diminishes, the colic ceases, and later the diarrhcva 
stops, the pain in the joints passes away, the purpuric spots gradually fade 
and disappear, and the child, although left in an exhausted condition, is 
otherwise well. 



1088 PEDIATRICS. 

There are very apt to be relapses, which may appear wdthin a few days 
or not for several weeks. 

These are the symptoms of a typical case ; but there are many variations. 
As a rule, the younger the child the more typical is the case. Sometimes 
the purpuric spots closely simulate urticaria. They may occur, although 
rarely, in the mouth. They sometimes simulate the lesion of erythema 
nodosum. The attacks of colic have a paroxysmal character. There may 
be swelling of the joints. 

The disease is rarely fatal unless it is complicated by some such disease 
as nephritis or endocarditis. 

The treatment is purely symptomatic. 

The most severe form of purpura which occurs is that which is called 
"purpura hsemorrhagica (morbus maculosus Werlhofii). The hemorrhages 
in this form are from the mucous membranes as well as into the skin. The 
disease begins with debility. A few days later purpuric spots appear on the 
skin, and subsequently h?ematuria and haemoptysis occur, from which ex- 
cessive anaemia may result. There is usually slight fever. When recovery 
takes place it is gradual, usually occupying two or three weeks. 

The prognosis is unfavorable in early life, as death may take place from 
the exhaustion following loss of blood or from hemorrhage into the brain. 
The diagnosis of purpura haemorrhagica is to be made from scorbutus by 
the general history of the case, and by the absence, if teeth are present, 
of stomatitis ulcerosa. 

Very malignant purpura haemorrhagica may occur, sometimes proving 
fatal within twenty-four hom^s. This form of purpura is usually spoken 
of as 2^urpu7'a fidminans. It is most commonly met with in infants and 
in very young children, and is characterized by cutaneous hemorrhages 
which develop with great rapidity, death sometimes taking place before 
there has been any hemorrhage from the mucous membranes. I have 
met with the reports of only seven or eight cases of this malignant form 
of purpura. 

A case of this kind was placed under my care by Dr. W. L. Richardson. 

The infant (Case 529) was seven months old, had always been perfectly healthy, and 
was being nursed by its mother, who was a healthy, strong woman and had a number of 
other healthy children. The father was also a remarkably strong and healthy man. This 
infant, without noticeable previous symptoms, suddenly developed this severe form of 
purpura. Large ecchymoses appeared upon the buttocks and on the trunk, and the infant 
rapidly failed in strength, and died in twenty-four hours. There was no hemorrhage from 
the mucous membranes. 

DIABETES MELLITUS. — In connection with other diseases associated 
with nutrition I shall mention diabetes mellitus, a disease in which sugar 
accumulates in the blood and is excreted in the urine. The origin of the 
disease is not known. It is a rare disease in early life. 

There does not appear to be any especial difference between the symp- 
toms and course of the disease in children and those which are met Avith 



UNCLASSIFIED DISEASES. 1089 

in adults. A voracious appetite, marked thirst, progressive ansemia, and 
sometimes emaciation, witii the passage of large quantities of urine of a 
high specific gravity and containing from five to ten per cent, of sugar, are 
commonly present. Owing to the irritation from the urine, incontinence is 
quite frequent. 

The prognosis is unfavorable, though cases' of recovery have been 
reported. The duration of the disease varies from a lew days to a number 
of months and even years. 

The treatment is to reduce the amount of sugar and starch in the food 
as much as possible. The diet which is most beneficial is milk. I have 
not found that there is any especial drug which is useful in the treatment 
of diabetes mellitus. Codeia, from 0.003 to 0.01 gramme (^ to J grain) 
three times daily, has been thought to be useful in reducing the amount 
of sugar in the urine. 

I have met with cases in which there was a transient appearance of 
sugar in the urine in such diseases as nephritis following scarlet fever. In 
these instances the sugar disappeared from the urine as the disease in which 
it occurred improved. 

DIABETES INSIPIDUS. — Diabetes insipidus is a disease characterized 
by the passage of large quantities of urine having a low specific gravity and 
not containing sugar or other abnormal elements. 

The etiology and origin of this affection are not known. It is a very 
rare disease, but is more common in early life than diabetes mellitus, and has 
been known to be congenital. 

Intense thirst, a dry skin, disturbance of the surface circulation, and 
general nervous symptoms are common in this disease. The children are 
not apt to show the emaciation which occurs in diabetes mellitus. 

Diabetes insipidus is essentially chronic, and so few post-mortem ex- 
aminations have been made of children dying with this disease that our 
knowledge concerning it is very limited. There are no drugs which ap- 
pear to be of benefit in its treatment. The essential part of the treatment 
is to protect the child from exposure and to see that it is warmly dressed, 
as sudden changes from heat to cold are liable to increase the general 
symptoms. 

Death usually results from some intercurrent affection. Spontaneous 
cures have been known to occur. 

TUBERCULOSIS. — Tuberculosis is a very prevalent affection in early 
life. While, according to Osier, it is very rare in the new-born, and 
uncommon in the first three months of life, after this age the number of 
cases increases very rapidly, and it is very common in the latter part of the 
first year and in the second year. 

I have already described the cause of tuberculosis when speaking of 
tuberculosis of the lung (page 993), and therefore I need not again describe 
the bacillus tuberculosis. 

It is now supposed that tuberculosis is hereditary in the sense that the 

69 



1090 PEDIATRICS. 

infant inherits tissues which are favorable to the development of the dis- 
ease^ unless in the rare cases where direct intra-uterine infection has taken 
place. 

I have spoken of the manner in which the bacillus tuberculosis gains 
access to the infant's tissues, either by inhalation or in the food. I have 
also described the manner in which the bacillus tuberculosis affects the 
various organs, such as the lung, pleura, pericardium, brain, liver, intestine, 
and lymphatic glands, especially the mesenteric glands. 

I shall not attempt to describe the various lesions which may occur in 
tuberculosis when localized, but shall in a few words describe the general 
tuberculosis which occurs so frequently in infancy. 

Acute Miliary Tuberculosis. — Acute miliary tuberculosis appears 
to be more common in the young than in adults. There is always some 
nidus from which the general infection takes place. The disease occurs as a 
secondary affection in children who are already tubercular. 

After a variable period of loss in weight and general health, which 
especially occurs in cases where acute miliary tuberculosis is secondary to 
measles or pertussis, the infant begins to have an irregular type of fever, 
cough, and general symptoms, such as diarrhoea, capricious appetite, and 
change of temperament. In some cases the disease advances very rapidly, 
but often it is of a subacute type, and frequently, unless the tuberculosis 
markedly affects some organ, such as the lung, the symptoms are very 
obscure, and cannot be diagnosticated from infantile atrophy, death finally 
taking place from exhaustion or from the development of some localized 
tuberculous coudition, such as a tubercular meningitis. In my experience, 
this form, which has been called the typhoidal type of the disease, and also 
the latent forms, are peculiarly difficult to diagnosticate. 

Chronic Diffuse Tuberculosis. — Where instead of the miliary 
lesions which characterize acute miliary tuberculosis a chronic diffuse form 
of tuberculosis arises, the symptoms are more marked, and usually are so 
closely connected with the bronchial lymphatics and the lungs that it is 
more easily diagnosticated. This latter is one of the more common forms 
of tuberculosis in children. 

The prognosis of general tuberculosis in early life is very unfavorable, 
and there is no known treatment which is of any benefit. 

In order to illustrate how extremely latent and masked may be the 
symptoms of miliary tuberculosis, I shall show you the results of a post- 
mortem examination which has just been made on an infant dying of that 



This infant (Case 530) was seven months old, and was in the hospital from October 
until December. During the time that it was in the hospital it became extremely emaciated, 
diarrhoea occurred from time to time, and there was an irregular and varying temperature, 
which was never especially high. It had a purulent discharge from the right ear and a 
serous discharge from the left ear about a week before its death. There were no other 
symptoms, but it failed rapidly, and died yesterday. 



U^X'LASSIFIED DISEASES. 



1091 



Anatoraical Diagnosis. 

Miliary tuberculosis of tlie pleura, spleen, kidney, and liver. 

Chronic tuberculosis of the bronchial lymph-glands and of the lung. 

Broncho-pneumonia. 
Here is an infant (Case 531), one and one-half years old, who was brought to the 
hospital a few days ago to be treated for an attack of bronchitis. On entrance it was much 
emaciated, and it has since been rapidly failing. I am able to find no marked signs beyond 

Case 531. 




(General tuberculosis. ^Multiple abscess. Infant, 1}'2 years old. 



a subacute bronchitis. There is at times a slight cough, the temperature is moderately 
raised and of an irregular type, and I suspect that the disease is one of the latent forms of 
general tuberculosis with a tubercular broncho-pneumonia. On examining the chest, back, 
and legs, especially the buttocks, you will notice that there are numerous subcutaneous 
abscesses of various sizes, and there are also a few on the head. These abscesses are prob- 
ably of a tuberculous nature, and a provisional diag- 
nosis of general tuberculosis, with involvement of 
the skin and the subcutaneous tissues, can be made. 

(Subsequent history.) The temperature in this 
case had been of an irregular type, and not especially 
raised until five days before the infant died, when 
it began to rise, and is as represented in this chart 
(Chart 50). 

The post-mortem examination, made by Dr. 
Mallory, showed that there was chronic tuberculosis 
of the bronchial glands, with acute miliary tuber- 
culosis of the pleura, lungs, spleen, kidneys, liver, 
and meninges of the brain. 

In addition to general tuberculosis, there 
are certain localized forms of the disease. 
The more important of these I have already 
spoken of, but I have here a boy (Case 532, 
page 1092)j nine years old, who, when three 
years old, had a localized tuberculosis of 
the little finger (tubercular dactylitis) of his 
left hand, which has recovered entirely. 

I have had him brought here to show 
you how completely these localized forms of tuberculosis may recover, and 
I shall call your attention to the cases of tubercular and syphilitic dactylitis 
which I showed you in a previous lecture (pages 502, 509). 

The only other important form of tuberculosis which I have not yet 







CHART 


50. 








Days of Disease 




T^. 














c. 


107 
106 
105 


:M E 


M E 


M E 


ME 


M E 


M E 


41.6° 
41.1° 
40.5^ 
'40 O'' 


























c 

104 












1 


103 
102 












Q 


39.4° 

38.8° 

38.3° 

37.7° 

37.2° 
37.0° 
36.6° 

36.1° 
35 5° 








V 


/ 




101 
.00 

99 

NORMAL 








\ 










/ 








^ 














/ 









98 
97 
96 
95 




^ ■ 1 






































35.0' 



Acute miliary tuberculociis. 



1092 PEDIATRICS. 

dwelt upon is localized tuberculosis of the cervical lymph-glands. These 
I shall speak of in connection with non-tuberculous adenitis. 

Case 532. 




Complete recovery from tubercular dactylitis. 

EPIDEMIC INFLUENZA.— Epidemic influenza is an acute, highly 
infectious disease, caused by a specific organism which has been described 
by Pfeiffer. 

The period of incubation is short, usually a few hours ; relapses are 
common ; one attack does not protect from another. 

Symptoms. — The symptoms of influenza are very variable. At times 
they are the same in children as in adults, but in infants and young children 
the symptoms are often not so severe as in the adult, although they vary in 
different epidemics, as do those of the adult. It is a characteristic of epi- 
demic influenza that it has no distinct group of symptoms of its own. The 
symptoms are chiefly a catarrhal affection of the nose and throat, and fre- 
quently of the bronchi. These symptoms in young children are accompanied 
evidently by great discomfort, at times amounting to pain, in the limbs and 
body, although on account of the age of the patient it is impossible to deter- 
mine whether much pain is present. Sometimes the only marked symptom 
is a heightened and irregular temperature, with marked apathy, and the 
disease may be so slight as to be recognizable only during an epidemic. In 
older children the symptoms, although, as a rule, not of so severe a type 



UNCLASSIFIED DISEASES. 1093 

as in adults, are at times quite serious, especially if continuous vomiting 
occurs. Severe headache and delirium are present in some cases, and ex- 
treme emaciation, out of proportion to the fever or to the morbid conditions 
detectable on physical examination. Severe symptoms connected with the 
larynx and the lungs may also arise and rapidly disappear. 

Diagnosis. — The diagnosis of epidemic influenza is often difficult, un- 
less influenza is present in the community, and is to be made by the careful 
elimination of other diseases. 

Prognosis. — The disease in itself is not dangerous, but complications 
are especially liable to arise and make the prognosis much more serious. 
These complications are very numerous. They may be meningitis, otitis, 
ileo-colitis, broncho-pneumonia, and lobar pneumonia. The most common 
and dangerous complication of influenza is pneumonia, which is usually a 
broncho-pneumonia, and is of serious import, especially if the child is de- 
bilitated at the time of the attack by some previous disease. 

Treatment. — In the treatment of epidemic influenza in infants and 
children I have found that drugs have very little effect upon the general 
discomfort caused by the pain. Small doses of phenacetine, 0.0,6 gramme 
(1 grain) once in three or four hours, with ten or fifteen drops of brandy, 
seem to yield as good results as any other mode of treatment. Where there 
is severe and continuous vomiting, small doses of iced champagne by the 
mouth and enemata of bromide of potassium, and, if necessary, hydrate of 
chloral, are indicated. The diet should be milk and beef tea. 

During the epidemic of influenza which occurred in Boston in 1891 I 
had under my care at the Infants' Hospital seven infants, varying in age 
from a few months to one and a half years, all of whom had epidemic in- 
fluenza. The symptoms were such as I have described. The infants cried 
continuously, the temperature was slightly raised, 37.7° to 38.3° C. (100° 
to 101° F.), and the duration of the attack was about one week. Pneu- 
monia occurred in two of the cases, and in both of these the infants died. 
Here are the charts (Charts 51 and 52, page 1094) showing the temperature 
in these cases during the course of the influenza, and the rise when the 
infants were attacked with pneumonia. 

I have in my notes the report of another case, where an attack of in- 
fluenza was complicated on the eleventh day of the disease by a lobar 
pneumonia. 

The infant (Case 533), sixteen months old, was attacked with catarrhal symptoms of 
the nose and throat, a slight cough, and a temperature of 40.5° C. (105° F.). The respira- 
tions were only slightly increased ; the pulse was rapid. Nothing abnormal was found on 
physical examination. The infant was very fretful, had no appetite, cried incessantly, and 
seemed to have considerable discomfort. On the ninth day from the onset of the attack 
the temperature fell to 39.1° C. (102.5° F.), and on the following day to 38.6° C. (101 5° 
F.). On the evening of this day the infant, who had begun to be brighter and to notice 
its playthings, again seemed very sick. Its respirations increased in frequency, there was 
motion of the alas nasi, and the temperature rose to 40.8° C. (105.4° F.). On the folKm'- 
ing day the temperature fell in the morning, but began to rise in the evening, and by the 



1094 



PEDIATRICS. 



next day had reached 41.0° C. (105.8° P.). On this da}^, the thirteenth from the begin- 
ning of the attack and the third from the fresh invasion, marked absolute dulness was 

CHAETS 51 AND 52. 





Influenza. 


Pneumonia. ^^^V^ 


Of Disease,^^^^^^^ 


Pneumonia. 


w. 


1 


2 


3 


4 


6 


1 


2 


3 




























c. 


107 
106 
105 
104° 
103° 
102° 
101 
100° 
99° 

NORMAL 
TEMP. 

98° 
97 

96 

o 

95 


M E 


M E 


M E 


M E 


M E 


M E 


ME 


M E 


M E 


ME 


ME 


ME 


M E 


ME 


ME 


ME 


M E 


M E 


M E 


ME 


M E 


41.6° 
41.1° 
40.5° 
40.0° 
39.4° 
38.8° 
38 3° 


















-s: 










































.Q 








































/ 


























■s: 
















/ 




















/ 


//il 












/ 
























/ 






/ 


/ 


/I 








/ 






















/ 










/ 


/ 


X^ 


/ 


^ 


/ 










/ 


/ 


/ 


/ 
















37.7^ 

37.2' 
37.0° 
36.6° 

36.1° 

35.5° 

35.0° 






















/ 


/ 


/ 


/ 




































/ 





























































































































































































Infantile atrophy. Epidemic influenza. 
Pneumonia. Male, 4 months old. 


Previously healthy. Epidemic influenza. 
Pneumonia. Female, 3 months old. 


CHART 53. 


/nfluenza. 


Days Of Disease. p„,,^onia. 




IT. 


8 


4 


5 


6 


7 


8 


9 


10 


1 


2 


3 


4 


5 


6 


7 


8 


9 


10 


11 


12 


13 


C. 


107 
106 
106 
104 
103 
102 
101 
100 
99 

NORMA! 

TEMPp 

98 
97' 
96° 

95 


M E 


M E 


M E 


M E 


M E 


M E 


ME 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


41.6° 
41.1° 
40.5° 
40.0° 

39.4° 

38.8° 

38.3° 

37.7° 

37.2° 
37.0' 
36.6° 

36.1° 

35.5° 

35.0° 
















































y 




^ 








i 




/ 






















/ 


/I 


y 






/ 








/ 


/ 






































/ 


/ 


/ 


/ 


y 






























^-^ 


[ 


/ 


/ 




/ 


/ 
































^ 


/ 










\ 




^ 


















































































\ 




\ 















— - 


























— 












W- 


^. 


k 


^ 




























































































































_ 





Epidemic influenza. Pneumonia. Recovery. Male, 16 months old. 



detected in the right lower back, with bronchial respiration and increased tactile and 
vocal fremitus. This area of dulness increased, and finally inv(jived the whole lower lobe 
of the right lung. On the fourth day of this new invasion the temperature fell to 38.8° C. 



UNCLASSIFIED DISEASES. 1095 

(102° r.) ; on the following day it rose to 39.7° C. (103.5° F.) in the evening, and in the 
next two days gradually fell to 37.2° C. (99° F.). On the following day it rose to 38.6° C. 
(101.5° F.), and in the next forty-eight hours fell gradually to 36.6° C. (98° F.). At this 
time the dulness began to disappear, moist rales appeared, the infant became much better, 
and in a few days, although very weak, seemed bright and well, and the physical signs in 
the lung had entirely disappeared. 

Here is the chart (Chart 53), which shows the temperature during ten days of the 
influenza, when a lobar pneumonia appeared and ran a course of five days, after which 
the temperature gradually fell to the normal point. It is possible that this case was one of 
pneumonia from the beginning of the attack, but it showed all the characteristic symptoms 
of epidemic influenza, and no dulness was found in the lung until the infant had apparently 
recovered from its influenza. 

DISEASES OP THE THYROID GLAND.— The thyroid gland is 
a highly vascular organ. It covers the front and sides of the upper part 
of the trachea, and also extends up onto the larynx. Its function is not 
known. I shall not describe such diseases of the thyroid gland as exoph- 
thalmic goitre, which are very rare in early life, but shall refer only to 
those morbid conditions which you are most likely to meet with, — namely, 
hyperemia, inflammation, hypertrophy, and complete absence. Absence of 
the thyroid gland, disturbance of its function, or actual disease of its tissues, 
are usually accompanied by peculiar symptoms. 

Hyper^emia. — A temporary congestion of the rich vascular tissue of 
the thyroid gland occurs under various conditions, such as the approach of 
puberty. This condition is usually so transient as to be scarcely noticeable 
so far as the symptoms are concerned, but sometimes it is sufficient to cause 
dyspnoea from pressure. This usually trivial condition has been thought, 
however, in certain cases to lead to the production of one of the forms of 

goitre. 

Case 534. 




Hyperaemia of the thyroid glaud. Female, 13 years old. 

This girl (Case 534), thirteen years old, was first noticed to have a swelling of the thy- 
roid gland two or three weeks ago. The swelling is becoming more prominent. The cuta- 



1096 PEDIATRICS. 

menia have not appeared. The girl is well and strong, but is somewhat more fretful and 
capricious than appears to be in accordance with her usual temperament. The tumor is 
elastic, does not fluctuate, and is not red or tender. She seems to represent one of that 
class of cases in which continued hyperaemia of the thyroid vessels occurring at puberty 
leads to enlargement of the gland. It is possible that a spontaneous lessening in the size of 
the tumor may take place when the catamenia have been established, but we know so little 
about this class of cases that the prognosis as to complete recovery must be very guarded. 
The treatment of this case will be the external application of iodine. 

Thyroiditis. — Acnte inflammation of the thyroid gland is not very 
common (Delafield and Prudden), but may occur from a variety of causes. 
It may result in the formation of abscesses of various sizes or in the produc- 
tion of new connective tissue. According to Osier, acute thyroiditis is rarely 
primary, being commonly a metastatic affection occurring in the course of 
some febrile disorder. It has been noticed among children as a complication 
of measles, and the process in a number of these recorded cases, instead of 
retrograding spontaneously as it did in others, caused an inflammatory con- 
dition in which abscess-formation occurred. On opening the abscesses the 
pus was found to contain numerous micrococci. 

The symptoms of acute thyroiditis are swelling and redness of the 
gland. 

The treatment is essentially expectant, but some previously intractable 
cases seem to have been benefited by the application of iodine. The patient 
should be carefully watched, and, if there are indications that suppuration 
has taken place, an incision should be made at once, as recovery then usually 
occurs quite quickly. 

Enlargement of the Thyroid Gland (Goitre; Bronchocele). — 
Enlargement of the thyroid gland is commonly called goitre. True goitre 
consists in the enlargement of the old and the formation of new alveoli in 
the cells of which a greater or less amount of colloid degeneration takes 
place. The colloid abnormalities of goitre are rarely present in children 
(Rex), in whom the thyroid enlargement seems to be little more than a 
continuation of the natural growth, and a true hypertrophy or an excessive 
development of normal tissue. 

Infants have been born with an enlarged thyroid. 

Myxcedema. — Myxoedema is a constitutional affection characterized 
clinically by a myxoedematous condition of the subcutaneous tissues and 
by mental failure, caused by a disturbance of the function of the thyroid 
gland. 

There are certain general symptoms which accompany disturbance of 
the thyroid function, whether from entire or partial absence of the gland, 
or from disease of its tissues, such as atrophy. These symptoms are hebe- 
tude, with a general thickening of the tissues, and in young individuals a 
great lack of development, both mental and physical. It is probable that 
it is a diflerence in degree or in kind of thyroid disturbance which produces 
the other symptoms so characteristic of myxoedema. These symptoms I 
shall presently describe to you in connection with the especial case^. 



UNCLASSIFIED DISEASES. 1097 

These various disturbances of the thyroid function may be endemic or 
sporadic. The endemic cases are represented for the most part by symp- 
toms peculiar to disturbance of the thyroid function, and also, where goitre 
is present, by symptoms of mechanical pressure. Cases of goitre without cre- 
tinism may, however, occur sporadically, and the sporadic cretin, as a rule, 
has no goitre. Atrophy of the thyroid gland may or may not be accom- 
panied by goitre. I shall not speak further concerning endemic cretinism, 
which occurs in certain localities, such as portions of Switzerland, and is de- 
pendent apparently on some unknown endemic cause which is also liable to 
produce goitre. As a race, cretins are distinguished by their stunted stature, 
large, deformed heads, sickly-looking countenances, coarse and prominent 
lips and eyelids, wrinkled and pendulous skin, loose and flabby muscles, 
and imperfect mental development, to which are often added goitres of all 
sizes. 

In certain individuals there is a congenital absence of the thyroid gland. 
This is a condition found in sporadic cretinism, in which the function of 
the thyroid gland is lost, just as its function is disturbed in goitre and in 
atrophy of the gland. 

Where the thyroid gland has been removed surgically there is at times a 
condition similar to that which is met with in myxoedema. This condition 
has been called by Horsley cachexia strumipriva. 

The head in sporadic cretinism is usually brachycephalic ; that is, it is 
contracted in its antero-posterior diameter and increased in its transverse 
diameter. Yirchow was the first to observe that in these cases there is a 
premature ossification of the spheno-basilar bone. The sphenoid and the 
basi-occipital bones should remain separate until about the fifteenth year, 
and their early ossification explains, according to Virchow, the changes 
which take place in the form of the cretin skull and face. The character- 
istics of the cretin bone are an enormous overgrowth of cartilage, an arrest 
of growth at the distal ends of the bones, and a premature ossification of 
the shaft. Here is the tibia (Fig. 148, IL, page 1066) of a cretin child. 
The section was made by Dr. Whitney, and is distinguished, as you see, 
anatomically by the almost entire absence of the zone of proliferation. 
This narrow line (Z. P.) marks the boundary between the broad area of 
cartilage above and the prematurely ossified bone of the shaft below. 

This little girl (Case 535), whom I have had brought to the hospital to show you, and 
who is just able to stand, and looks as though she were about one and a half years old, 
seems to be a case of myxoedema. 

She is five and a half years old. Her parents were healthy Americans, not blood 
relations, and did not have goitre. She was born after a severe labor: it was a head 
presentation, and no instruments were used. Nothing especially abnormal was noticed 
about her until the twelfth month, when she did not seem so bright as is usual at that age 
When four years old she was brought to the hospital. She could not speak, and her 
mental condition was much enfeebled. She had never had any convulsions, but had always 
had incontinence of urine and of fiieces. When seen a year later she appean^i to be in 
good general condition, but her muscles were large and Habby and she had not improved 
mentally. The circumference of her head is 40.5 cm. (18| inches). The moasuroinent 



1098 



PEDIATRICS. 



from the occiput to the root of the nose is 34.4 cm. (13^ inches), across the head from ex- 
ternal meatus to external meatus 29.3 cm. (11^ inches). The circumference of the thorax 
is 40.3 cm. (15| inches). There are no irregularities about her head. The forehead is 
overhanging, and this is rendered more striking on account of the sunken bridge of the 
nose. The lips are thick, and the tongue, which seems enlarged, is protruded between them. 
The hearing is said to be good, and the sight is good. She has been able to sit alone since 
she was one year old, but can stand only with support, and cannot walk. She is bow- 
legged, and the bones are somewhat enlarged about the epiphyses. The hands and feet are 
large and puffy, but do not pit. The feet are bright red, tbe hands less so. The trunk is 
stout and thick ; the spine is straight; the lungs and heart are normal, and I can detect 
nothing abnormal about the abdomen except an umbilical hernia. The tendon reflexes 
are normal. Sensation is good. The thyroid gland is not felt. The teeth are good. There 

Case 535. 




Myxoedema. Female, 5>^ years old. 

is a general condition of infiltration of the skin like myxoedema. Hebetude is marked. 
The treatment of this child will be with an extract made from the thyroid gland of a sheep, 
as this seems to be the only means which we at present know of by which a certain 
number of these cases are benefited. I have not treated a sufficient number of cases 
personally to judge whether the thyroid treatment will eventually prove successful. Other 
observers, however, claim to have obtained decided improvement, both physical and men- 
tal, by its use. I shall order .06 c.c. (1 minim) of the thyr;)id extract at first three times 
daily, and gradually increase 1 minim every two days until the rectal temperature rises 
above 37.7° C, (100° P.). If during the course of the treatment the temperature should 
rise over 37.7° C. (100° F.), the extract should be omitted for a day or two. In this way you 
can determine the proper dose for the especial case. I shall also warn the parents that the 
child must be kept warm, and be removed to a southern climate in the colder months. 



UNCLASSIFIED DISEASES. 



1099 



I have under my care a little girl (Case 536), two years old, who appeared to be per- 
fectly well and strong during her first year, but did not learn to sit or creep until the last 
few months, and who cannot stand alone or walk. There are no signs of rhachitis about the 
child, except that the anterior fontanel le is not closed. Nothing abnormal is found on 
physical examination, except that the tissues of the hands and feet are thickened and the 
skin is dry and cold, with at times a bluish tint. She has always held her mouth open and 
protruded her tongue, which seems to be thicker than normal. She is phlegmatic, and does 
not care to play. The bowels are constipated. There is no enlargement of the thyroid. 
Her case seems to be one of myxoedema. 

She has been under treatment two months with the extract of the thymus gland. 
During this period she has grown much brighter mentally, and now creeps about more, 
wishes to play, and takes more interest than formerly. The tongue is not so much enlarged 
as before the treatment was begun, and the bowels are no longer constipated. Several times 
during the course of the treatment the thyroid extract has had to be omitted, as it seemed 
to cause digestive disturbance with a rise of temperature, 37.7° or 38.3° C. (100° or 101° F.). 
Omitting the thyroid extract for twenty-four hours, these symptoms would pass away, and 
it could then be given again. 

This case (Case 537) is one of great interest, as it represents so typically the mental and 
physical characteristics of sporadic cretinism. I am enabled to show it to you through the 
courtesy of Professor Northrup, who gives the following account of it : 



Case 637. 




Myxoedema. Female, 9 years old. Slight improvement after eighty days' treatment with thyroid extract. 



"The parents of the child were healtby Americans from Western Pennsylvania, and 
they were not consanguineous. The father was 45 years old ; the mother was 30 years of 
age, had had several miscarriages and four healthy children, two of whom had died of some 
acute disease. This little girl, who is now nine years old, is the fifth child. The mother 
first noticed that the child could not sit up when it was nine months-old, that it practically 
ceased to grow, and now at nine years it is mentally no older than it was at nine months, and 
physically it has merely thickened. The first impression one gets on looking at the child 



1100 PEDIATRICS. 

is that it is an idiot. Its hands are large and broad. Its color is peculiarly sallow. The 
hair is thin, long, dry, and without lustre. The eyebrows are present, and are not remarka- 
ble in any way. She has the characteristic flattening of the bridge of the nose, diffuse 
swelling of the under lid and puffiness of the upper lid, and pendulous cheeks. She has 
thick, pale lips, with a protruding tongue, which is swollen and pale. The lips and tongue 
have a tendency to dryness. There are fourteen teeth, all of them of the first set. Those 
in the upper row are eroded, and appear only at the bottom of a series of ulcers in the 
upper gums. The lower teeth are in nearly the same condition, and the gums are sup- 
purating. An olfensive odor is always present in the mouth. The arms, legs, feet, and 
hands are unnaturally thick. The abdomen is prominent, and there is, as you see, an 
umbilical hernia. The hand which is resting on its mother's black glove shows the dry, 
wrinkled condition so characteristic of myxoedema. Perspiration is absent. The skin is 
pale, and has a peculiar mottled appearance. The soles of the feet and the palms of the hands 
are dry. There is marked lordosis. The surface of the child does not suggest the feeling 
of oedema, nor does it pit. The feeling is that of puffiness and flabbiness. The child can- 
not sit alone. It can, however, stand when once balanced and allowed to grasp some fixed 
object. The supraclavicular ' pad' of tissue so commonly found in these cases is present. 
The thyroid gland seems to be present, and is possibly enlarged. Hebetude is shown to a 
marked degree, and the delayed cerebration is very evident, although the child never speaks 
except to say, with infinite slowness, ' da — da.' 

" (Subsequent history.) The rectal temperature four days before treatment was begun 
was 36.4° C. (97.5° F.) in the morning, and 37.5° C. (99.5° F.) in the evening. The 
child was treated with the thyroid extract prepared so that each drachm represented one 
thyroid gland of a yearling. Of this preparation 0.06 c.c. (1 minim) was given three 
times a day until the fourth day, when the temperature rose above 37.7° C. (100° F.), 
and the treatment was stopped for a day. At this time the appetite had improved, and 
the breath was not so ofiensive. Two days later the treatment was begun again, and on 
the eighth day the tongue was found to be considerably smaller. During the next week 
the temperature remained under 37.7° C. (100° F.). It then rose above 37.7° C. (100° F.), 
and the treatment was suspended. The first tooth, a canine, was cut at this time. The 
largest dose which was given during the treatment was 0.24 c.c. (4 minims) three times a 
day. The child was treated eighty days in this way. The improvement was very slight, 
but the countenance was brighter, the tongue became much smaller, and the skin less 
dry. She lost somewhat in weight while under treatment. The constipation, which was 
marked when the treatment was begun, disappeared, and she was willing to take a much 
greater variety of food." 

Through the kindness of Professor Osier I am enabled to show you 
this little girl (Case 538), who is four years old. 

The parents were healthy, and there was no hereditary taint on either side of the family, 
none of whom have had goitre. She was the second child : the labor was easy, and she 
throve well. She has never had any diseases. Nothing especial was noticed about the child 
until its second year, when it was observed that she did not attempt to walk or talk, and that 
she seemed unnaturally quiet and dull. She did not cut her first teeth until she was two 
years old. In her third year her skin became very pale and waxy, and her face and limbs 
seemed puffy and swollen. She had developed very little mentally, and could say only one 
or two words. The other symptoms indicative of a disturbance of the function of the 
thyroid gland gradually appeared, such as the myxoedematous condition of the subcutaneous 
tissues and the development of the supraclavicular pad. The thyroid gland could not be 
felt. The examination of the blood showed a moderate increase of leucocytes and some 
irregularity in the size of the erythrocytes. When three and a half years old she was 75 
cm. (29f inches) tall, and her head measured 52.3 cm. (20| inches). She had been under 
treatment with tonics for a year, and was reported to take more notice and to look more 
intelligent. She was then treated with the thyroid extract, and has improved markedly in 
both her mental and her physical condition. The tongue, which had been thick and pro- 



UNCLASSIFIED DISEASES. 1101 

trading, is fast recovering its normal size. She can walk and talk a little, and Dr. Osier 
thinks that she may be considered to represent a case in which the thyroid extract has pro- 
duced decided improvement. 

Case 538. 




Myxoedema. Female, 4 years old. Marked improvement under thyroid treatment. 

DISEASES OP THE CERVICAL LYMPH-GLANDS.— The chain 
of lymphatics in the neck is so closely connected with the lymphatics of the 
mouth and throat that infection frequently takes place. I have already 
spoken of the enlargement of the cervical glands secondary to absorption 
in cases of diphtheria. Localized enlargement of the cervical glands occurs 
also in tuberculosis, and sometimes is the only manifestation of that disease. 
The cervical glands may also be enlarged in lymphatic leucaemia and in 
multiple sarcoma. 

Here is a little girl (Case 539) who has, in addition to marked chronic tuberculosis of 
the lungs, enlargement of the cervical glands, which is very probably of tubercular origin. 

When the tubercular disease is advanced in other organs there is seldom much benefit 
to he derived from the treatment of these glands. I show you this case more for the 
purpose of comparison with some other cases having enlarged cervical glands than for any- 
thing of especial interest in connection with this class of advanced tubercular cases. 

The cervical glands may be enlarged from a number of causes, as well 
as from direct infection througli the throat. Any irritation of the scalp, 
ears, eyes, nose, throat, gums, or teeth may cause a temporary or permanent 



1102 PEDIATRICS. 

enlargement of the cervical glands. In some few cases they enlarge with- 
out apparent cause, except that the children are ansemic or debilitated. In 
these cases they often run a rather acute course, and may subside without 
suppuration having taken place. In other cases suppuration quickly takes 
place, and in these, as well as where a number of these glands enlarge and 
coalesce, and where the enlargement lasts for long periods, we should always 
suspect that the ba( illus tuberculosis is present in the glands. 

Case 539. 




Chronic pulmonary tuberculosis, with involvement of the cervical lymph-glands. 

The first effort in undertaking the treatment of these cases should be to 
seek for and remove the peripheral source of irritation which exists in most 
cases. Decayed teeth should be extracted, eczema of the scalp should be 
treated, and in all cases as much as possible should be done to diminish any 
irritation in the area of surface drained by the cervical lymphatics. During 
the active stage of cervical adenitis it is better not to make any application 
to the glands, but to treat any general disturbances, such as anaemia or 
debility, which may be present. When the active process has subsided and 
a chronic condition is left, the glands may become quiescent or may go on 
to suppuration. In the treatment of this chronic condition you should take 
into consideration the possibility that the glands may eventually suppurate 
and leave unsightly scars. As a rule, it is bettet* to have these cases placed 
in the hands of a surgeon and the glands removed, as there are no especial 
contra-indications to the operation, and the scar left when the operation is 
skilfully performed is slight. 



UNCLASSIFIED DISEASES. 



1103 



I have here a little girl (Case 540) in whom the cervical lymphatics are enlarged to 
such an extent that they have become a deformity. 

Nothing else abnormal nor any other symptom of tuberculosis can be discovered about 

Case 540. 





T. 






m 


1 


If 


-^ I 


f. 




S^^H^Hi 


^r 


•^^^ '^''^M 


■HI 


^ 




I^^^Hl 


W^ 


'"W^ 


hhb 


f 


■ 


t--^"i/^-< 






Chronic cervical adenitis. 



Chronic cervical adenitis (after treatment). 



the child. These glands should have been removed before they reached such a size as this, 
as now on their removal a considerable scar will be left. 

(Subsequent history.) The glands were removed, and the picture shows what good 
results can be obtained in these cases by surgical interference. 

Case 541. 




Enlargemient of submaxillary glands. 



The submaxillary glauds are enlarged in children from various causes, 
but sometimes from no discoverable cause. At times the enlargement of 
the glands is accompanied by pain and tenderness, constituting a disease 



1104 PEDIATRICS. 

which has been called submaxillary mumps. In the beginning, however, 
we should not at once make this diagnosis, as the glands may become en- 
larged and tender from various causes which have no connection with the 
specific disease mumps. 

Here is a little girl (Case 541, page 1103), two years and four months old, who is an 
illustration of this class of cases. She was suddenly attacked yesterday with a swelling 
of the submaxillary glands, accompanied by pain and a slight amount of tenderness over 
the swollen region. She has a history of exposure to parotitis. To-day the swelling has 
extended under the entire chin and up the left side of the neck to the face and ear. 

The diagnosis in a case of this kind must be held in abeyance for a few days, and 
strict isolation should be enforced, as if the cause of the glandular enlargement proves to 
be infectious other children should be protected. 

(Subsequent history.) The swelling, pain, and tenderness lasted for a number of days 
and then gradually subsided. Nothing more definite was discovered regarding the case. 

PAROTITIS (Mumps). — Parotitis is a highly infectious disease which 
attacks the parotid gland. Its period of incubation is from two to three 
weeks. The onset of the attack is usually accompanied by a sense of chilli- 
ness, a rise of temperature, and a sensation of stiffness and tenderness about 
the jaws. This is succeeded by a swelling in the region of the parotid gland, 
which becomes enlarged and tender, rendering deglutition difficult and 
often very painful. The disease begins on one side, but the other gland 
is usually involved in a day or two. As I have just stated, the infection 
is sometimes confined to the submaxillary glands on one or both sides. 

The duration of an attack of parotitis is from a few days to a week, 
but the infection may last for two or three weeks, and it has been stated 
in some cases to antedate the appearance of the glandular enlargement. In 
boys at the age of puberty the complication of orchitis at times arises. 

Although the symptoms of parotitis are commonly very mild, unusual 
cases sometimes occur in which the children are quite sick, and there have 
been cases in which the orchitis was of so high a grade that acute delirium 
supervened, and in one case reported by Dukes the boy fainted when the 
orchitis began. 

It is sometimes difficult to differentiate parotitis from a simple non- 
infectious enlargement of the parotid gland or of the glands in its neighbor- 
hood. When the parotid gland is enlarged it usually shows a characteristic 
swelling under and behind the lobe of the ear, so that the lobe is pushed 
somewhat upward and forward. This swelling increases rapidly, is very 
tender, is not especially reddened, does not fluctuate, and is accompanied 
by constitutional symptoms. The diagnosis is readily made if after a few 
days the unilateral swelling is followed by corresponding symptoms on the 
opposite side. 

Here is a boy (Case 542, page 1105), twelve years old, who was attacked five days ago 
with swelling and tenderness in the region of the parotid gland, followed in a short time 
by stiffness and pain at the angle of the jaw, and accompanied by symptoms of loss of appe- 
tite and a heightened temperature. 

Two days later the parotid of the opposite side was involved. You will notice how 



UNCLASSIFIED DISEASES. 



1105 



the neck in the part which corresponds to the position of the parotid is swollen on both 
sides, and how the characteristic swelling which pushes the ear upward and forward is 
seen on looking at the child from behind. 

Case 542. 





Parotitis. Male, 12 years old. 

There is no especial treatment for the disease, as it is self-h'mited and 
runs a definite course. The children should be carefully isolated, in order 
that there may be no further spread of the infection. As deglutition is 
painful, their diet is usually milk and soups. They should be carefully 
protected from exposure, and should be confined to their rooms. Older 
children should be confined to bed, as orchitis in boys and trouble with the 
mammae in adolescent girls are less likely to arise under these conditions. 
It is usually better to apply some soft cotton wool to the painful swelling, 
and to protect it from any irritation. 

DISEASES OP THE EAR.— We have, gentlemen, studied the nor- 
mal infant at birth, and have followed it through its various stages of de- 
velopment into childhood, up to the age of puberty. I have also en- 
deavored to make you familiar with the various morbid conditions which 
are most likely to arise during these early periods of life. 

Before closing this course of lectures, however, I wish again to call 
your attention to the great importance of bearing in mind, in examining 
mfants and children, the common occurrence of some morbid process in the 
ear. In many cases where the more pronounced aural symptoms are not 
evident, symptoms which appear obscure, but really are due to some latent 
disturbance in the neighborhood of the ear, reflex or otherwise, are readily 
explained when in addition to the presence of some other disease the un- 
usual symptoms are found to arise from the aural complication. The ques- 
tion of diseases of the ear in infancy and childhood has not received 
from the general practitioner, nor indeed from those who devote themselves 
especially to children, the attention that it deserves. Even leaving out of 

70 



1106 PEDIATRICS. 

consideration the cases of disease of the middle ear incident to the exan- 
themata, which I have already dwelt upon (page 558) when speaking of 
these diseases, serious implications of the ear from other causes are not 
uncommon during the first year of life. 

Von Troltsch found on examining forty-seven petrous bones taken from 
twenty-four unselected children that the middle ear was normal in only 
eighteen. The other twenty-nine ears showed in varying degrees the ap- 
pearance of a purulent and sometimes, though rarely, of a mucous catarrh. 
Of the fifteen children with exudation in the middle ear, the youngest was 
three days and the oldest one year old ; five were in their first month, two 
each in their second and fourth, three in their third, and one each in their 
seventh, eighth, and twelfth months. 

In every five examinations of the ears of new-born children Schwartze 
found the tympanum filled with pus in two. 

Wreden found in eighty ears of children a normal middle ear in only 
fourteen ; purulent catarrh existed in thirty-six, and simple mucous catarrh 
in thirty ; the youngest child had lived twelve hours, the oldest fourteen 
months. The majority of these cases were, however, from three to fourteen 
days old. 

Edward Hoffman examined twenty-four petrous bones in infants vary- 
ing in age from thirty -two hours to four weeks, and found the tympanum 
filled with pus in seven cases. 

Of two hundred and thirty carefully examined cases under seven 
months of age Kutcharianz found the tympanic mucous membrane normal 
in thirty only. In fifty it showed either slight or intense catarrhal inflam- 
mation, and in one hundred and fifty the tympana were filled with pus. 

These statements, quoted from Von Troltsch, serve to emphasize the 
statement of that author that even from the beginning of extra-uterine life 
"there is an unusually strong disposition to disease of the middle ear, 
owing on the one hand to the double influence of the peculiar morphological 
relations of the ear and the pharynx, and on the other hand to the diseases 
and conditions of life to which the child is frequently exposed.'^ 

We should therefore consider carefully the ear in all cases where the 
symptoms are obscure, as well as where those diseases are present in which 
it is well known that aural complications are liable to arise. 

The late Dr. Edward H. Clark made a statement, which has since been 
largely quoted by other writers on otology, to the effect that the physician 
who neglected the examination of the ear in the course of the exanthemata 
of childhood might be denominated an unscrupulous practitioner. The 
statistics which I have just given you show that not only the possible im- 
plication of the ear in scarlet fever and measles, but also the inflammation 
in the tympanic cavity consequent upon acute catarrhal inflammations of 
the nose and naso-pharynx, as well as the reflex disturbances, should receive 
your closest attention. 



INDEX. 



Abdomen in the new-born infant, 44. 

of the premature infant, 291. 
Abdominal band, 133. 

organs, normal development of, 77. 
Abnormal effects of vaccination, 152. 
Abscess, cerebral, 648. 

prognosis of, 648. 
treatment of, 648. 

peritonsillar, 815. 

retro-pharyngeal, 817. 
Acquired disease, definition of, 19. 
Acute catarrhal gastritis, 854. 

corrosive gastritis, 856. 

coryza, 801. 

cystitis, 942. 

fatty degeneration of the new-born, 
440. 

follicular pharyngitis, 816. 

gastric indigestion, 844. 

gastritis, 854. 

laryngitis, 951. 

miliary tuberculosis, 1090. 

nephritis, 932. 

peritonitis, 920. 

rhinitis, 801. 

simple pharyngitis, 815. 

tonsillitis, 809. 

tubercular broncho-pneumonia, 994. 

tuberculosis of the lung, 993. 

yellow atrophy of the liver, 915. 
Adenoid growths, 806. 
Adolescence, urine of, 114. 
Air-passages, upper, syphilis of the, 490. 
Albuminuria, physiological, 927. 
Alopecia areata, 461. 

treatment of, 462. 
Amnesia, temporary, 739. 
Amyloid infiltration of the kidney, 938. 

liver, 916. 
Anaemia infantum pseudo-leukaemica, 359. 

progressiva perniciosa, 356. 

rhachitic, 368. 



Anaemias, primary, 355. 

secondary, 365. 
Anatomy, topographical, of the early periods 

of life, 120. 
Anencephalia, 409. 
Anencephalocele, 409. 
Animal heat of premature infants, 295. 

parasites, 908. 
Anterior poliomyelitis, 609. 
Antitoxin, 829. 
Anuria, 946. 
Anus, fistula of the, 880. 

imperforate, 433. 

syphilitic condylomata of the, 494. 
Apparatus for feeding, 232. 

for feeding at home, 262. 
Appendicitis, 888. 

diagnosis of, 889. 

etiology of, 888. 

prognosis of, 889. 

symptoms of, 888. 

treatment of, 890. 
Appendix vermiformis, anatomy and de- 
velopment of, 92. 
Arrested physical development, 740. 
Arteries, umbilical, 20. 
Artery, common carotid, 43. 

pulmonary, 43, 76. 
Arthritis, acute, of infants, 1086. 
Artificial foods, 154. 
Ascaris lumbricoides, 910. 

symptoms of, 911. 

treatment of, 911. 
Asiatic cholera, 887. 
Asphyxia, 440. 
Asthma, etiology of, 1004. 

pathology of, 1005. 

prognosis of, 1005. 

symptoms of, 1005. 

treatment of, 1005. 
Ataxia, hereditary, 689. 

pathology of, 689. 
prognosis of, 689. 
symptoms df, 689. 

1107 



1108 



INDEX. 



Ataxia, hereditary, treatment of, 689. 
locomotor, 689. 

diagnosis of, 689. 
pathology of, 689. 
Atelectasis, 979. 
Athetosis, 661. 

diagnosis of, 661. 
pathology of, 661. 
prognosis of, 661. 
treatment of, 661. 
Atrophic rhinitis, 804. 
Atrophy, acute yellow, of the liver, 915. 
infantile, 869. 

diagnosis of, 869. 
pathology of, 869. 
prognosis of, 870. 
symptoms of, 869. 
the blood in, 377. 
treatment of, 870. 
myopathic progressive muscular, 763. 
diagnosis of, 765. 
pathology of, 764. 
prognosis of, 765. 
symptoms of, 764. 
treatment of, 765. 
neuropathic progressive muscular, 763. 
of the intestine, 869. 
progressive muscular, 763. 
Auscultation of the sick child, 322. 
Autumnal catarrh, 1005. 

B. 

Bahcock milk- tester, 249. 

Back, care of the, 143. 

Bacteriological examination of human milk, 

180. 
Barley jelly, 282. 

water, 281. 
Basin as used in bathing the infant, 129. 
Bath, temperature of the, 129. 
Bathing, 128. 

Bed for a child, characters of, 126. 
Bile in the new-born infant, 52. 

normal development of the. 111. 
Bile-ducts, congenital obstruction of the, 
438. 

pathology of, 438. 

symptoms of, 438. 

treatment of, 440. 
Bilious attack, 862. 
Birth-paralysis, 438. 
Bladder at end of term, 24. 

in the new-born infant, 48. 

normal development of the, 78. 

reflex of the, 752. 



Blood, bibliography of the, 398. 
chemistry of the, 334. 
foetal, 337. 
in individual diseases, 370. 

broncho-pneumonia, 373. 

chorea, 376. 

diphtheria, 372. 

empyema, 373. 

hydrocephalus, 375. 

icterus neonatorum, 379. 

infantile atrophy, 377. 

malaria, 380. 

measles, 371. 

miliary tuberculosis, 374. 

nephritis, 376. 

parasites of the, 380. 

periostitis, 378. 

peritonitis, 377. 

pneumonia, 372. 

and empyema, 373. 

scarlet fever, 371. 

sclerema neonatorum, 379. 

scorbutus, 379. 

tubercular meningitis, 374. 

typhoid fever, 370. 

variola, 371. 
in infancy and childhood, 330. 
in premature infants, 348. 
in the foetal circulation, 19. 
in the new-born infant, 52, 349. 
key, 331. 

literature of the, 329. 
nomenclature of the, 380. 
normal, at birth, 339. 

color of, 339. 

development of, 111. 

haemoglobin of, 340.^ 

reaction of, 339. 

specific gravity of, 339. 
origin of the, 336. 
Blood-vessels, malformations of the, 440. 
Bone, normal development of, 107. 
Bone marrow in the new-born infant, 51. 
Brain, diseases of the, 594. 
dura mater of the, 65. 
growth of the, 65. 
in the new-born infant, 37. 
normal development of the, 64. 
subarachnoid space of the, 65. 
Branchial fistula, 417. 
Breast-pump, 162. 
Broken cells, 345. 
Bronchitis, 954. 
acute, 955. 

diagnosis of, 957. 

pathology of, 955. 



INDEX. 



1109 



Bronchitis, acute, prognosis of, 957. 
symptoms of, 955. 
treatment of, 957. 
chronic, 961. 
fibrous, 962. 
Bronclio-pneumonia, 962. 

complications of, 972. 
diagnosis of, 972. 
etiology of, 962. 
pathology of, 963. 
symptoms of, 969. 
the blood in, 373. 
treatment of, 973. 
chronic, 979. 
Brooder, 309. 

apparatus connected with the, 313. 
Broth, chicken, 287. 

mutton, 287. 
Buhl's disease, 440. 

C. 

Ctecum in the new-born infant, 47. 

normal development of, 92. 
Cancrum oris, 788 
Capacity of the stomach, 79. 
Caput succedaneum. 404, 
Caries of the spine, paralysis caused by, 

688. 
Carpet, the, in the nursery, 126. 
Catalepsy, 735. 
Catarrh, acute gastric, 854. 
autumnal. 1005. 
chronic gastric, 856. 
periodic, 1005. 
Catarrhal ophthalmia, 415. 

stomatitis, 776. 
Ceiling, the, in the nursery, 126. 
Cephalhaematoma, 404. 
Cerebral abscess, 648. 
paralysis, 648. 
sinuses, thrombosis of, 626. 
Cerebro-spinal meningitis, 692. 
diagnosis of, 694. 
etiology of, 693. 
pathology of, 693. 
, prognosis of, 695. 
symptoms of, 694. 
treatment of, 696. 
sclerosis, multiple, 691. 
Cervical glands, effect of scarlet fever upon, 

537, 555. 
Chicken broth, 287. 
Chicken-pox, 524. 

Child, distinction of, from infant, 18. 
Chlorosis, 355. 



Cholera Asiatica, 887. 

Cholera infantum, diagnosis of, 886. 

etiology of, 885. 

pathology of, 885. 

prognosis of, 886. 

symptoms of, 885. 

treatment of, 886. 
Chorea, 711. 

etiology of, 712 

pathology of, 712. 

prognosis of, 713. 

s^Tnptoms of, 713. 

the blood in, 376. 

treatment of, 714. 
Chronic bronchitis, 961. 

cystitis, 942. 

diffuse tuberculosis, 1090. 

gastric catarrh, 856. 

interstitial nephritis, 937. 

laryngitis, 952. 

parenchymatous nephritis. 933. 

peritonitis, 921. 

tonsillitis, 812. 

tuberculosis of the lungs, 996. 
Chyluria, diagnosis of, 941. 

etiology of, 941. 

symptoms of, 941. 

treatment of, 941. 
Circulation in the fcetus, 19. 

in the premature infant, 295. 

post-natal changes in the, 21. 
Cirrhosis of the liver, 917. 
Cleft palate, 412. 
Clock, the, in the nursery, 132. 
Closets and drawers, 127. 
Clothing, 132. 

Club-foot, treatment of, 436. 
Club-hand, treatment of, 436. 
Colon, ascending, normal development of, 
92. 

descending, normal development of, 94. 

dilatation of the, 875. 
Color of fscal dejections, 274. 
Colostrum, 166. 
Common carotid artery, 43. 
Concussion, 738 

Condylomata, syphilitic, of the anus, 494. 
Congenital disease, definition of, 19. 

form of hernia, 428. 

hydrocephalus, 409. 

malformations of the stomach, 440. 

obliteration of the intestine, 440. 

obstruction of the bile-duct?, 438. 

umbilical hernia into the curd, 425. 
Constipation, atonic, 868. 

spasmodic. 868. 



1110 



INDEX. 



Contraction of the stomach, 848. 
Centra-indications to maternal feeding, 159. 
Convulsions, 754. 

prognosis of, 757. 
treatment of, 758. 
Cord, spinal, 676. 

umbilical. See Umbilical cord. 
Corpuscles, nucleated red, 342. 
Coryza, acute, 801. 
Cough, reflex, 751. 

Cow, the, as a source of milk-supply, 218. 
Cranium of the new-born infant, 31. 
normal development of the, 64. 
Cricoid cartilage, normal development of 

the, 599. 
Curtains in the nursery, 127. 
Curvatures of the spine, 143. 
Curves of the spine, 56. 
Cystitis, acute, 942. 

etiology of, 942. 
prognosis of, 942. 
symptoms of, 942. 
treatment of, 942. 
chronic, 942. 

prognosis of, 943. 
sj^mptoms of, 943. 
treatment of, 943. 



Dactylitis syphilitica, 496. 

Defects of posture, 142. 

Degeneration, acute fatty, of the new-born, 

440. 
Dejections, fsecal, color of, as influenced by 
the percentage of fat in the food, 274. 
odor of, 274. 
Dental reflexes, 746. 
Dentition, difficult, 794. 
Dermatitis exfoliativa neonatorum, 464. 
Descent of the testicle, 432. 
Developmental diseases of the intestine, 858. 
Diabetes insipidus, 1089. 

mellitus, 1088. 
Diaphragm in the new-born infant, 41. 
Diarrhoea, acute, 860. 

symptoms of, 861. 
treatment of, 861. 
prophylaxis of, 858. 
Difficult dentition, 794. 
Digestive disturbances in hereditary syphilis, 

493. 
Dilatation of the colon, 875. 

of the stomach, 848. 
Diphtheria, complications and sequelae of, 
826. 



Diptheria, etiology of, 821. 

incubation of, 823. 

pathology of, 823, 

prognosis of, 827. 

prophylaxis of, 828. 

symptoms of, 823. 

the blood in, 372. 

treatment of, 828. 

variations in type of, 824. 
Disinfection in scarlet fever, 549. 
Draughts in the nursery, 127. 
Dress, 135. 
Drugs in lactation, 184. 

use of, 326. 
Duodenum in the new-born infant, 45. 



E. 

Early periods of life, topographical anatomy 

of, 120. 
Eczema, 470. 
Eliminative disturbance of the intestine, 

872. 
Elongation of the uvula, 816. 
Empyema, 1013. 
Encephalocele, 408. 
Endocarditis, diagnosis of, 1033. 

etiology of, 1031. 

pathology of, 1031. 

prognosis of, 1034. 

symptoms of, 1032. 

treatment of, 1034. 
Enlargement of the thyroid gland, 1096. 
Enuresis, etiology of, 946. 

prognosis of, 948. 

symptoms of, 948. 

treatment of, 948. 
Eosinophiles, mononuclear, 344. 

polynuclear, 344. 
Epididymitis, 944. 

Epiglottis, normal development of the, 59. 
Epilepsy, diagnosis of, 726. 

etiology of, 724. 

prognosis of, 727. 

symptoms of, 725. 

treatment of, 727. 
Epispadias, 435. 
Epistaxis, 805. 
Erysipelas, 512. 

ambulans, 512. 

migrans, 512. 

of the new-born, 513. 

of sucklings, 513. 

pathology of, 512. 

treatment of, 514. 



INDEX. 



1111 



Erythema, 465. 

symptoms of, 465. 
treatment of, 466. 
. intertrigo, 466. 

neonatorum, 108. 

nodosum, 466. 
Erythrocytes at birth, 340. 

in foetal blood, 338. 
Eustachian tube in the foetus, 20. 

normal development of the, 66. 

post-natal changes in the, 21. 
Evolution of vaccination, 151, 
Exanthemata, 517. 
Eye at time of birth, 24, 

in the new-born infant, 37, 

F. 

Face in the new-born infant, 31. 

normal development of the, 64, 
Fffical dejections, color of. 274. 

odor of, 274. 
Fatty degeneration, acute, of the new-born, 
440. 
diagnosis of, 440. 
etiology of, 441. 
pathology of, 441. 
prognosis of, 441. 
symptoms of, 440. 
treatment of, 442. 
infiltration of the liver, 915 
Feeding, amount at each, 234. 
apparatus for, 232, 262. 
contra-indications to maternal, 159. 
difficulties of, 154. 
direct substitute, 209. 
general principles of. 153. 
general remarks on substitute, 230. 
indirect substitute, 214. 
intervals of, 181. 
maternal, 158, 159. 
method of, 285. 
mixed, 205. 

of average infants born at term, 272. 
of premature infants, 299. 
Feet, care of the, 138. 
club, 436. 

in the new-born, 49. 
malformations of the, 436. 
normal development of the, 105. 
of premature infants, 293. 
Femoral hernia, 430. 
Fender, 130. 

Fermental diseases of the intestine, diagno- 
sis of, 881. 
etiology of, 880. 



Fermental di-seases of the intestine, prog- 
nosis of, 88 1 . 

symptoms of, 880, 

treatment of, 882. 
Fibrous bronchitis, 962. 
Fingers, malformations of the, 436. 
Fissures, 879. 
Fistula, branchial. 417. 

of anus, 880. 
Floor, the, in the nursery, 126. 
Foetus, blood of the, 337. 

circulation in the, 19. 

post-natal changes in the, 21. 
Fontanelle, anterior, 30. 

posterior, 31. 
Fontanelles, normal development of the. 63. 
Food, amount of, taken, 90. 

management of, and increase in weight, 
tables showing, 264. 
Foramen ovale in the foetus, 20, 

post-natal changes in the, 21, 
Foreign bodies in the larynx, 950. 

in the oesophagus, 834, 
Formation of milk, the, 164, 
Freckles, 481. 
Friedreich's disease, 689. 
Fruits, 286, 

Functional diseases of the intestines, 860. 
Functions in the new-born infant, 51. 

normal development of the, 110. 
Fungus of the umbilicus, 425. 
Funicular form of hernia, 428. 
Furniture of the nursery, 127. 
Furunculosis, treatment of, 459. 



Gall-bladder, normal development of the, 77. 
Gastric indigestion, acute. 844. 

chronic, 845. 
Gastritis, acute, 854, 

catarrhalis acuta, 854. 
pathology of, 854. 
symptoms of, 854. 
treatment of, 855. 
catarrhalis chronica, 856. 
patbology of, 857. 
prognosis of, 857. 
symptoms of, 857. 
treatment of, 857. 
corrosiva acuta, 856. 
pseudo-menibranosa, 850. 
Glands, diseases of the cervical lymph-. 1101, 

mammary, 155. 
Glossitis, 793. 
Goitre, 1096. 



1112 



INDEX. 



Granules occurring in human blood, 345. 
Gums in the new-born infant, 32. 
lancinsc of the, 796. 



H. 



Hsematoma of the sterno-cleido-mastoid 

muscle, 416. 
Hsematuria, 940. 
Haemoglobin at birth, 340. 
Haemoglobinsemia, infectious, of the new- 
born, 448. 

etiology of, 445. 

literature of, 446. 

pathology of, 444. 

symptoms of, 444. 

treatment of, 446. 
Hsemoglobinuria, 940. 

etiology of, 940 
Haemophilia, 451. 
Hair at birth, 24. 
Hand, club, 436. 
Hands in the new-born infant, 49. 

malformations of the, 436. 
Harelip, 409. 
Hay fever, 1005. 
Head at birth, 404. 

circumference of the, 60 

of, relative to the thorax, 60. 

of the premature infant, 291. 
Headache, 741. 
Heart, 42. 

acquired diseases of, 1027. 

congenital diseases of, 1020. 
diagnosis of, 1026. 
prognosis of, 1027. 
symptoms of, 1025. 
treatment of, 1027. 

diseases of, 1019. 

effect of scarlet fever on, 541. 

functional diseases of, 1027. 

inflammatory lesions of, 1030. 

in the new-born infant, 42. 

malformations of, 440. 

mechanical conditions of, 1030. 

normal development of, 74. 

organic diseases of, 1028. 

position of, at term, 24. 

reflexes of, 751. 

syphilitic, 490. 

weight of, 74. 
Heat, animal, of premature infants, 295. 
Heat-stroke, 736. 
Heating the nursery, 127. 
Height in the new-born infant, 49. 

normal development of, 96. 



Hemorrhage from the umbilical cord, 54. 

in early life, 446. 
Hemorrhoids, 880. 
Hepatitis, interstitial, 917. 
Hereditary ataxia, 689. 

syphilis, digestive disturbances in, 493. 
insomnia a symptom of, 494. 
Hernia, 879. 

congenital form of, 428. 

umbilical, into the cord, 425. 
femoral, 430. 
funicular form of, 428. 
infantile form of, 428. 
inguinal, 427. 
treatment of, 428. 
umbilical, 426. 
Herpes zoster, 478. 
diagnosis of, 479. 
symptoms of, 478. 
treatment of, 479. 
Hip, congenital dislocation of the, 437. 
Hives, 467. 
Hydrocele, 430. 

encysted, of the canal of Nuck, 431. 

of the cord, 430. 
treatment of, 431. 
H\'drocephalus, acquired internal, 642. 
diagnosis of, 643. 
prognosis of, 643. 
symptoms of, 643. 
treatment of, 643. 
congenital, 409. 
congenital internal, 634. 
diagnosis of, 636. 
operation for. 637. 
pathology of, 634. 
prognosis of, 636. 
symptoms of, 635. 
treatment of, 686. 
external, 630. 
internal, 634. 
the blood in, 375. 
Hydronephrosis, 941. 
etiology of, 941. 
prognosis of, 942. 
symptoms of, 942. 
treatment of, 942. 
Hygiene of the nursery, 125. 
Hypertrophic rhinitis, 804. 
Hypertrophy of the pharyngeal tonsil, 

806. 
Hypnotism, 735. 
Hypospadias, 485. 
Hysteria, 782. 

diagnosis of, 734. 
prognosis of, 734. 



INDEX. 



1113 



Hysteria, symptoms of, 733. 
treatment of, 734. 

I. 

Ichthyosis, foetal, 482. 

prognosis of, 483. 
symptoms of, 483. 
treatment of, 483. 
neonatorum, 483. 

treatment of, 484. 
Icterus, 914. 

neonatorum, 107. 
the blood in, 379. 
Idiocy, 670. 

diagnosis of, 671. 
pathology of, 670. 
symptoms of, 670. 
treatment of, 671. 
Ileo-colitis, 891. 

treatment of, 898. 
amoebic, 900. 
chronic, 906. 
tubercular, 906. 

pathology of, 907. 
symptoms of, 907. 
typhoidal, 900. 

diagnosis of, 902. 
pathology of, 901. 
prognosis of, 903. 
symptoms of, 901. 
treatment of, 903. 
Imperforate anus, 433. 
Impetigo contagiosa, 458. 
Impression, maternal, 404. 
Incontinence of faeces, 867. 

of urine, 946. 
Incubator, 301. 

Dr. Worcester's, 306. 
Indigestion, 844. 

acute gastric, 844. 
diagnosis of, 844. 
symptoms of, 844. 
treatment of, 844. 
chronic gastric, 845. 
symptoms of, 845. 
treatment of, 845. 
intestinal, 862. 
Infant, anatomical points of, 25. 
abdomen, 44. 
bile, 52. 
bladder, 48. 
blood, 52. 
bone-marrow, 51. 
brain, 37. 
caecum, 47. 



Infant, anatomical points of: common caro- 
tid artery, 43. 
cranium, 31. 
diaphragm, 41. 
duodenum, 45. 
ear, 37. 

Eustachian tubes, 35. 
eye, 37. 
face, 31. 
feet, 49. 
functions, 51. 
gums, 32. 
hands, 49. 
hard palate, 37. 
head, 30. 
hearing, 51. 
heart, 42. 
height, 49. 
Intestines, 47. 
jaws, 32. 
kidney, 44. 
lachrymal glands, 51. 
liver, 44. 
lung, 43. 

lymphatic system, 52. 
lymph-vessels of the pharynx, 35. 
meconium, 53 
mouth, 36. 
naso-pharynx, 32. 
neck, 30. 
pancreas, 52. 
pelvis, 48. 

petro-squamosal suture, 38. 
pulmonary artery, 43. 
pulse, 48. 
respiration, 40, 48. 
ribs, 38. 

salivary glands, 51. 
sebaceous glands, 51. 
sight, 51. 
smell, 51. 
spine, 27. 
sternum, 38. 
stomach, 45. 
supra-renal capsule, 44. 
sweat-glands, 51. 
taste, 51. 
teeth, 37. 
temperature, 48. 
thorax, 38. 
thymus gland, 42. 
tonsils, 35. 
touch, 51. 

uric acid infarction, 44. 
urine, 48, 53. 
veins, 43. 



1114 



INDEX. 



Infant, anatomical points of: vitality, 49. 
voice, 51. 
weight, 49. 

at term, 23. 

distinction of, from child, 18. 
Infantile atrophy of the intestine, 869. 

paralysis, pseudo-syphilitic, 496. 

tubercular meningitis, 612. 
Infantilism, 505. 

Infectious haemoglobin aemia of the new- 
born, 446. 
Inflammatory diseases of the intestines, 

887. 
Influenza, epidemic, 1092. 

diagnosis of, 1093. 

prognosis of, 1093. 

treatment of, 1093. 
Insanity, 731. 
Insolation, 736. 

diagnosis of, 737. 

prognosis of, 737. 

treatment of, 737. 
Insomnia a symptom of hereditary syphilis, 

494. 
Inspection of the mouth, 325. 

of the sick child, 320. 
Interstitial hepatitis, 917. 

keratitis, 506. 
Intertrigo, 132. 
Intestinal contents, 858. 

in premature infants, 294. 

discharges, 117. 

indigestion, 862. 
chronic, 863. 
Intestine, chronic functional diseases of the, 
863. 

congenital obliteration of the, 440. 

developmental, 858. 

diseases of the, 836. 

eliminative disturbances of the, 872. 

fermental, 880. 

functional, 860. 

infantile atrophy of the, 869. 

inflammatory, 887. 

in the new-born infant, 47. 

mechanical, 875. 

new growths of the, 887. 

normal development of the, 91. 

organic, 875. 

polypi of the, 880. 

prolapse of the, 879. 

tubercular, 861. 
Intra-cranial syphilis, 668. 

tumors, 662. 
Intussusception, diagnosis of, 877. 

prognosis of, 877. 



Intussusception, symptoms' of, 877. 
treatment of, 878. 



Jaws in the new-born infant, 32. 



K. 

Kaposi's disease, 481. 

Keratitis, interstitial, 506. 

Kidney, acute hj^persemia of the, 930. 

amyloid infiltration of the, 938. 

diseases of the, 927. 
acquired, 927. 
congenital, 927. 

effect of scarlet fever on the, 537, 580. 

in the new-born, 44. 

malignant growths and enlargements of 
the, 939. 

normal development of the, 78. 

of premature infant, 295. 

passive hypersemia of the, 931. 

syphilitic, 490. 

tumors of the, 939. 
Killian's observations on the tonsils, 36. 
Knee, congenital dislocation of the, 437. 



Laboratory, milk, 245. 

Lachrymal glands in the new-born infant, 
51. 

normal development of the, 110. 
Lactation, cases of disturbed, 190. 

diet of, 182. 

disturbed, 184. 

drugs during, 184. 

exercise during, 184. 

management of disturbed, 188. 

menstruation, effect of, on, 185. 

pregnancy, effect of, on, 186. 

prolonged, 205. 

regimen of, 182. 
Lancing the gums, 796. 
Laryngitis, acute, 951. 

diagnosis of, 952. 
symptoms of, 951. 
treatment of, 952. 

chronic, 952. 

pseudomembranous, 953. 
Laryngospasmus, 949. 
Larynx, diseases of the, 949. 

foreign bodies in the, 950. 

new growths of the, 949. 

normal development of the, 59. 



INDEX. 



1115 



Larynx, oedema of the, 950. 

reflex phenomena of the, 748. 
Legs, 146. 
Leiter's coil, 599. 

Length of spine, normal development of, 55. 
Lentigo, 481. 
Leptomeningitis, 595. 
Lesions of the mouth, syphilitic, 494. 
Leucaemia, 351. 
Leucocytes at birth, 340. 

in foetal blood, 338. 

large mononuclear, 343. 

percentages of various, in normal blood, 
346. 

poly nuclear, 343. 

small mononuclear, or lymphocytes, 343. 

transitional forms of, 343. 

varieties of, 343. 
Leucocytosis, 350. 
Lichen, 481. 
Liver, acute yellow atrophy of the, 915. 

amyloid, 916. 

at end of term, 24, 

cirrhosis of the, 917. 

diseases of the, 914. 

fatty infiltration of the, 915. 

icterus, 914. 

in the new-born infant, 44. 

normal development of the, 77. 

syphilitic, 489. 

tuberculosis of the, 915. 
Lobar pneumonia, 980. 
Locomotor ataxia, 689. 
Lungs, acute tuberculosis of the, 993. 

chronic tuberculosis of the, 996. 

diseases of the, 954. 

in the new-born infant, 43. 

normal development of the, 75. 

reflex of the, 750. 

syphilitic, 490. 
Lymphatic system in the ncAV-born infant, 52. 

normal development of the, 111. 
Lymph-glands, diseases of the cervical, 1101. 

M. 

Macroglossia, 794. 

Malaria, diagnosis between, and meningitis, 
609. 

diagnosis of, 387. 

pathology of, 386. 

prognosis of, 388. 

symptoms of, 388. 

the blood in, 380. 

method of examination of, 380. 

treatment of, 390. 



Malformations about the rectum, 433. 
congenital, of the stomach, 440. 
of the heart and blood-vessels, 440. 
Malignant growths and enlargements of the 

kidney, 939. 
Mammary gland, relation of micrococci to 

inflammation of the, 162. 
Marasmus (infantile atrophy), 869. 
Mastitis, 162, 418. 
Maternal feeding, contra-indications to, 159. 

impression, 404. 
Mattress, 127. 
Maxillary bones, normal development of 

the, 67. 
Measles, complications and sequelae of, 584. 
desquamation of, 578, 582. 
diagnosis of, 578. 
efliorescence of, 577, 582. 
incubation of, 576. 
pathology of, 574. 
prodromata of, 576. 
prognosis of, 578. 
symptoms of, 576. 
tiae blood in, 371. 
treatment of, 578. 
variations in type in, 581. 
Mechanical diseases of the intestines, 875. 
Meconium, 23, 53. 
Meckel's diverticulum, 426. 
Melanoderma lenticularis progressiva, 481. 
Meningitis, cerebro-spinal, 692. 
infantile tubercular, 612. 
prognosis of, 612. 
treatment of, 612. 
non-tubercular, 595. 
pathology of, 596. 
symptoms of, 598. 
treatment of, 599. 
tubercular, 603. 

diagnosis of, 608. 
difterential diagnosis of, 609. 
pathology of, 605. 
symptoms of, 605. 
the blood in, 374. 
Meningo-myelocele, 420. 
Menstruation during lactation, 185. 
Method of examining a sick child, 318. 
Microcephalus, 672. 
Micrococci, relation of, to inflammation of 

the breast, 162. 
Microglossia, 794. 
Migraine, 742. 
Milk, anal3^sis of bad, 187. 
cow's, 237. 
normal, 187. 
over-rich, 187. 



1116 



INDEX. 



Milk, analysis of poor, 187. 

ash of, 174, 241. 

ass's, 178. 

average analysis of human, 172. 

bacteriological examination of cow's, 
237. 
of human, 180. 

bacteriology of cow's, 242. 

chemical analysis of, 172. 

clinical examination of human, 169. 

constituents and properties of, 165. 

cow's, 178. 

cows producing suitable, 225. 

estimate of the proteids of, 171. 

fat of, 173. 

and proteids of, 170. 

-house, the, 225. 

human, 167. 

quality of, 168. 
quantity of, 167. 

-laboratory, the, 245. 

methods of examination of, 170. 

microscopic examination of, 169. 

nervous disturbances affecting the, 165. 

peptonized, 282. 

production of, 155, 164. 

reaction of cow's, 223, 236. 
of human, 172. 

-room, 247. 

salts of, 169. 

specific gravity of, 169, 170, 172. 

sugar of, 170, 174. 

tester, Babcock, 249. 

transportation of, 263. 

variations in human, 177. 

water of, 173. 
Mind, normal development of the, 110. 
Mirror writing, 673. 
Miscarriage caused by syphilis, 503. 
Modifying-room, 249. 
Molluscum contagiosum, 459. 
Mononuclear eosinophiles, 344. 

neutrophiles, 344. 
Mother, the nursing, 160. 
Mouth, diseases of the, 774. 

in the new-born infant, 36. 

inspection of the, 325. 

normal development of the, 67. 

syphilitic lesions of the, 494. 
Mucous polypus, 805. 
Multiple cerebro-spinal sclerosis, 691. 

neuritis, 704. 
Mumps, 1104. 
Mutton broth, 287. 
Myelitis, 676. 
Myelocytes, 344. 



Myopathic progressive muscular atrophy, 

763. 
Myopathies, 763. 
Myotonia congenita, 773. 
Myxoedema, 1096. 

N. 

Nsevus, 454. 

Napkins, 135. 

Naso-pharynx, diseases of the, 801, 805. 

in the new-born infant, 32. 

normal development of the, 65. 
Neck in the new-born infant, 30. 

normal development of the, 59. 
Nephritis, acute, 932. 

chronic interstitial, 937. 

parenchymatous, 933. 

the blood in, 376. 
Nervous disturbances affecting the milk, 165. 

system, diseases of the, 590. 
functional, 732. 
presumably organic, 711. 
Nettle-rash, 467. 
Neuralgia, 709. 
Neuritis, multiple, 704. 

diagnosis of, 705. 

etiology of, 704. 

pathology of, 704. 

prognosis of, 705. 

symptoms of, 704. 

treatment of, 705. 
Neuropathic progressive muscular atrophy, 

763. 
New-born, abdomen in the, 44. 

acute fatty degeneration of the, 440. 

caecum in the, 47. 

cranium of the, 31. 

diaphragm in the, 41. 

duodenum in the, 45. 

feet in the, 49. 

functions in the, 51. 

gums in the, 32. 

hands in the, 49. 

head in the, 30. 

height in the, 49. 

infectious hsemoglobinsemia of the, 446. 

intestine in the, 47. 

jaws in the, 32. 

kidney in the, 44, 

lachrymal glands in the, 51. 

liver in the, 44. 

lungs in the, 43. 

lymphatic system in the, 52. 

mouth in the, 36. 

naso-pharynx in the, 32. 

neck in the, SO, 



INDEX. 



1117 



New-born, pancreas in the, 52. 

paralysis of the, 706. 

pelvis in the, 48. 

petro-squamosal suture in the, 31 

pulse in the, 48. 

respiration in the, 40, 48. 

ribs in the, 38. 

salivary glands in the, 52. 

sebaceous glands in the, 28, 51. 

sight in the, 51. 

smell in the, 51. 

sternum in the, 38. 

stomach in the, 45. 

supra-renal capsules in the, 44. 

sweat-glands in the, 51. 

taste in the, 51. 

teeth in the, 37. 

temperature in the, 48. 

thorax in the, 38. 

thymus gland in the, 42. 

touch in the, 51. 

uric acid infarction in the, 44. 

urine in the, 53. 

uterus in the, 48. 

veins in the, 43. 

vitality in the, 49. 

voice in the, 51. 

weight in the, 49. 
New growths of the intestine, 887. 

of the larynx, 949. 

of the stomach, 854. 
Night-dress, 136. 
Night-terrors, 745. 
Nipples, 161. 

artificial, 233. 
Noma, 788. 

Non-tubercular meningitis, 595. 
Normal development : abdomen, 77. 

bile, 111. 

bladder, 78. 

blood. 111. 

blood-vessels, 75. 

bone marrow, 107. 

brain, 64. 

caecum and ascending colon, 92. 

cord, 54, 110. 

descending colon, 94. 

ear, 65. 

Eustachian tube, 66. 

face and cranium, 64. 

feet, 105. 

functions, 110. 

gall-bladder, 77. 

hard palate, 67. 

head. 60. 

heart, 74. 



Normal development : height, 96. 

infantile skeletons, 118. 

intestinal discharges, 117. 

intestine, 91. 

kidney, 78. 

lachrymal glands, 110. 

liver, 77. 

lungs, 75. 

lymphatic system. 111. 

maxillary bone, 67. 

mental impressions, 110. 

mouth, 67. 

naso-pharynx, 65. 

neck, 59. 

pancreas, 77, 111. 

petro-squamosal suture, 65. 

pharyngeal tonsil, 66. 

pulse, 94. 

respiration, 72, 96. 

salivary glands, 111. 

sigmoid flexure, 93. 

skin, 107. 

spine, 55. 

spleen, 77. 

sternum, 70. 

stomach, 79. 

supra-renal capsules, 78. 

sweat-glands, 110. 

teeth, 68. 

temperature, 94. 

thorax, 70. 

thymus gland, 72. 

thyroid. 111. 

topographical anatomy of the early 
periods of life, 120. 

urine, 111. 

vermiform appendix, 92. 

voice, 110. 

weight, 97. 
Northrup on the lung in the new-born 

infant, 43. 
Nose, diseases of the, 801. 

normal development of the, 65. 
Nuck, encysted hydrocele of the canal of, 431. 

treatment of, 431. 
Nucleated red corpuscles, 342. 
Nursery, hygiene of the, 125. 
Nursery-maids, 141. 
Nursing mother, the, 160. 
Nutritive period, second, 284. 

third, 287. 



Oats, 281. 

Obstruction, congenital, of the bile-ducts, 438 

Occlusion of the vagina, 435. 



1118 



INDEX. 



(Edema, acute circumscribed, 484. 

neonatorum, 484. 

of the larynx, 950. 
(Esophagitis, 834. 

(Esophagus, congenital malformation of the, 
440. 

diseases of the, 834. 

foreign bodies in the, 834. 
Oligocythaemia, 353. 
Onychia, syphilitic, 506. 
Ophthalmia, catarrhal, 415. 

neonatorum, 415. 

purulent, 415. 
Orchitis, 945. 

Organic diseases of the intestines, 875. 
Osseous system, syphilis of, 490. 

symptoms of, 49. 
Osteochondritis, syphilitic, 495. 
Oxyuris vermicularis, 908. 

diagnosis of, 909. 

treatme 
Ozsena, 804. 



Pachymeningitis, 595. 
Palate, cleft, 412. 
hard, 37, 67. 
Palpation of the sick child, 320. 
Pancreas, diseases of the, 918. 
in the new-born infant, 52. 
normal development of the, 77, 111. 
syphilitic, 490. 
Papers in the nursery, 126. 
Paralysis, birth, 438. 

caused by caries of the spine, 688. 
diagnosis of, 688. 
symptoms of, 688. 
cerebral, 648. 

diagnosis of, 652. 
etiology and pathology of, 649. 
prognosis of, 652. 
symptoms of, 650. 
treatment of, 654. 
infantile pseudo-syphilitic, 496. 
of the new-born, 706. 
diagnosis of, 707. 
etiology of, 706. 
pathology of, 707. 
prognosis of. 707. 
symptoms of, 707. 
treatment of, 708. 
pseudo-hypertrophic muscular, 768. 
prognosis of, 689. 
treatment of, 689. 
Parasites, animal, 908. 



Parasites of the blood, 380. 
Parotitis, 1104. 
Parrot's disease, 496. 
Pavor nocturnus, 745. 
Pediculosis, treatment of, 458. 
Pelvis in the new-born infant, 48. 
Pemphigus neonatorum, 462. 

treatment of, 463. 
Penis, 946. 

Peptonized milk, 282. 
Percussion of the sick child, 321. 
Pericarditis, diagnosis of, 1055. 
etiology of, 1046. 
pathology of, 1046. 
prognosis of, 1059. 
symptoms of, 1047. 
treatment of, 1059. 
Pericardium, diseases of the, 1046. 
Perineum, 918. 

diseases of the, 918. 
Period, nutritive, second, 284. 

third, 287. 
Periostitis, the blood in, 378. 
Peripheral nerves, 704. 
Peritonitis, acute, 920. 

pathology of, 920. 
prognosis of, 921. 
symptoms of, 920. 
treatment of, 921. 
chronic, 921. 
tubercular, 921. 

diagnosis of, 922. 
pathology of, 922. 
prognosis of, 922. 
symptoms of, 922. 
the blood in, 377. 
treatment of, 922. 
Peritonsillar abscess, 815. 
Pernicious anaemia, progressive, 356. 
Pertussis, 998. 

complications of, 1000. 
diagnosis of, 1001. 
pathology of, 999. 
prognosis of, 1001. 
prophylaxis of, 1003. 
symptoms of, 999. 
treatment of, 1001. 
Petro-squamosal suture in the new-born in- 
fant, 38. 
normal development of the, 65. 
Petticoat, 135. 
Pharyngeal tonsil, hypertrophy of the, 

806. 
Pharyngitis, acute follicular, 816. 
treatment of, 816. 
acute simple, 815. 



INDEX. 



1119 



Pharynx, diseases of the, 801, 809. 
Phimosis, 946. 

Physiological albuminuria, 927. 
Phlebitis and arteritis umbilicalis, 425. 
Pillow, the, 127. 

Pityriasis maculata circinata, 480. 
rosea, 480. 
rubra, 480. 
Placenta the lung of the foetus, 19. 
Pleura, diseases of the, 1007. 
Pleurisy, 1007. 

diagnosis of, 1009. 
pathology of, 1007. 
prognosis of, 1011. 
symptoms of, 1008. 
treatment of, 1012. 
purulent, 1013. 
Pneumonia, acute tubercular broncho-, 
994. 
diagnosis of, 995. 
prognosis of, 995. 
symptoms of, 995. 
treatment of, 995. 
lobar, 980. 

complications of, 986. 
diagnosis of, 985. 
etiology of, 980. 
gangrene in, 986. 
pathology of, 981. 
prognosis of, 986. 
symptoms of, 981. 
treatment of, 987. 
the blood in, 372. 
Poliomyelitis, 676. 

diagnosis of, 678. 
differential diagnosis of, 679. 
pathology of, 676. 
symptoms of, 677. 
treatment of, 681. 
anterior, diagnosis between, and menin- 
gitis, 609. 
Polynuclear eosinophiles, 344. 
Polypi of the rectum, 880, 887. 
Polypus, mucous, 805. 
Porencephalia, definition of, 650. 
Port-wine mark, 454. 
Position of the heart at term, 24. 
Posture, defects of, 142. 
Powder, 130. 

Pregnancy during lactation, 186. 
Premature infants, 288. 

amount of food at each feeding of, 

299. 
amylolytic function of, 294. 
animal heat of, 295. 
circulation of, 295. 



Premature infants, cleansing and clothing 
of, 301. 
composition of food for, 299. 
digestion of sugar of, 295. 
Dr. Worcester's incubator for, 306. 
fat and proteid digestion of, 295. 
feet of, 293. 

gastric capacity of, 293. 
head, thorax, and abdomen of, 291. 
incubators for, 301. 
intervals of feeding of, 299. 
intestinal contents in, 294. 
kidney of, 295. 

pathology of the blood in, 348. 
pulse, temperature, and respiration of, 

297. 
skin of, 292. 
sweat-glands of, 292. 
weighing of, 301. 
weight of, 290. 
Primary angemias, 355. 
Progressive muscular atrophy, 763. 
myopathic, 763. 
neuropathic, 763. 
pernicious ansemia, 356. 
Prolapse of the rectum, 879. 
Prolonged lactation, 205. 
Proteids, coagulation of, 239. 
estimation of the, 171. 
in human milk, 174. 

and cow's milk, 238. 
Prurigo, 478. 

treatment of, 478. 
mitis infantilis, 477. 
symptoms of, 477. 
treatment of, 478. 
Pseudo-hypertrophic muscular paralysis, 
768. 
diagnosis of, 769. 
treatment of, 771. 
-leuksemic ansemia of infants, 359. 
-membranous gastritis, 856. 

laryngitis, 953. 
-syphilitic infantile paralysis, 496. 
Psoriasis, 475. 

treatment of, 476. 
Puberty, age of, 18. 
Pulmonary artery, 43, 75. 
Pulse in the new-bom infant, 48. 
normal development of the, 94. 
of premature infant, 297. 
Purpura, 1086. 
Purulent ophthalmia. 415. 

pleurisy, 1013. 
Pyelitis, 938. 
Pyelo-nephritis, 938. 



1120 



INDEX. 



R. 



Eanula, 414. 

Eectum, malformations about the, 433. 
imperforate anus, 433. 

prolapse of the, 879. 

reflex of the, 752. 
Red corpuscles, nucleated, 842. 
Reflex cough, 751. 

of the bladder, 752. 

of the heart, 751. 

of the rectum, 752. 

of the stomach, 752. 

of the vagina, 752, 

phenomena of the larynx, 748. 
of the lungs, 750. 
Reflexes, dental, 746. 

Respiration in the new-born infant, 40, 
48. 

normal development of, 72, 96. 

of the premature infant, 297. 

of the sick child, 320. 
Retarded speech, 740. 

Retro-pharyngeal abscess, diagnosis of, 
817. 

pathology of, 817. 

prognosis of, 818. 

symptoms of, 817. 

treatment of, 818. 
Rhachitic ansemia, 368. 
Rhachitis, congenital, 1071. 

diagnosis of, 1073. 
, etiology of, 1065. 

pathology of, 1066. 

prognosis of, 1073. 

symptoms of, 1073. 

treatment of, 1073. 
Rheumatism, diagnosis between, and tuber- 
cular meningitis, 611. 

etiology of, 1080. 

pathology of, 1080. 

prognosis of, 1081. 

symptoms of, 1081. 

treatment of, 1081. 
Rhinitis, acute, 801. 

atrophic, 804. 

hypertrophic, 804. 

purulent, 803. 
Ribs in the new-born infant, 38. 

movement of the, 39. 
Ringworm, 460. 
Rose cold, 1005. 
Rotheln, 588. 
Rubella, 588. 
Rubeola, 573. 
Rugs in the nursery, 126. 



S. 



Salivary glands in the new-born infant, 52. 

normal development of the. 111. 
Scabies, 456. 

treatment of, 457. 
Scales, 128. 

systematic and frequent use of, 99. 
Scarlet fever, 532. 

cervical glands in, 537. 

complications of, and their treatment, 
555. 

contagium of, 533. 

desquamation of, 544. 

diagnosis of, 545. 

ear in, 536. 

efilorescence of, 542. 

heart in, 541. 

incubation of, 542. 

isolation and disinfection in, 549. 

kidney in, 537. 

malignant form of, 572. 

pathology of, 534. 

prodromata of, 542. 

prognosis of, 545. 

symptoms of, 542. 

the blood in, 371. 

throat in, 535. 

treatment of, 545. 

urine of, 544. 

variations in the benign form of, 552. 
School, 142. 
Sclerema neonatorum, 453, 484. 

blood in, 379. 

symptoms of, 454. 

treatment of, 453. 
Scleroderma, 484. 
Sclerosis, definition of, 650. 

multiple cerebro-spinal, 691. 
diagnosis of, 692. 
etiology of, 691. 
pathology of, 691. 
prognosis of, 692. 
symptoms of, 691. 
treatment of, 692. 
Scorbutus, blood in, 379. 

diagnosis of, 1077. 

etiology of, 1075. 

pathology of, 1075. 

prognosis of, 1078. 

symptoms of, 1076. 

treatment of, 1078. 
Sebaceous glands in the new- born infant, 

23, 51. 
Seborrhoea capitis, 132. 
Second nutritive period, 284. 



INDEX. 



1121 



Secondary angemias, 365. 

Sensitive spine, 744. 

Separating-room, 248. 

Separator, 248. 

Shirt, 135. 

Shoes, 138. 

Sight in the new-born infant, 51. 

Sigmoid flexure, normal development of the, 

93. 
Simulated diseases, 735. 
Sinuses, cerebral, thrombosis of, 626. 
Skeletons, infantile, 118. 
Skin, 24. 

diseases of the, 455. 

normal development of the, 107. 

of premature infants, 292. 
Sleep, 14 

Smell in the new-born infant, 51. 
Soap, 129. 

Speech, retarded, 740. 
Spina bifida, 419. 
Spinal curves, 27. 

meningocele, 420. 
Spine at time of birth, 26. 

curvatures of the, 143. 

curves of the, 56. 

flexibility of the, 56. 

length of the, 55. 

normal development of the, 55. 

paralysis caused by caries of the, 
688. 

prominent processes of the, 58. 

sensitive, 744. 

surface anatomy of the, 58. 
Spleen, diseases of the, 918. 

normal development of the, 77. 

position of the, at birth, 25. 

syphilitic, 489. 
Sponges, 129. 

Statistics of vaccination, 147. 
Sterilizer, 252. 

home, 276. 
Sterno-cleido-mastoid muscle, haematoma of 

the, 416. 
Sternum, depressed, 418. 

in the new-bom infant, 38. 

normal development of the, 70. 

ossification of the, 39, 71. 

prominent, 419. 
Still, 249. 
Stockings, 136. 

Stdhr's observations on the tonsils, 36. 
Stomach, capacity of the, 79. 

congenital malformations of the, 440. 

contraction of the, 848. 

developmental diseases of the, 840. 



Stomach, diagnosis between diseases of the, 
and meningitis, 609. 
dilatation of the, 848. 
diagnosis of, 850. 
pathology of, 849. 

prognosis of, 851. 
symptoms of, 850. 

treatment of, 851. 
diseases of the, 609, 836. 

diagnosis of, 838. 

etiology of, 837. 

general bacteriology of, 837. 

pathology of, 837. 

symptomatology of, 838. 

treatment of, 839. 
functional diseases of the, 840. 
inflammatory diseases of the, 854. 
in the new-born infant, 45. 
nervous diseases of the, 840. 
new growths of the, 854. 
normal development of the, 79. 
of the premature infant, 293. 
organic diseases of the, 848. 
reflex of the, 752. 
ulcers of the, 853. 
Stomatitis catarrhalis, 776. 

pathology of, 777. 

prognosis of, 777. 

symptomatology of, 777. 

treatment of, 778. 
gangrgenosa, 788. 

diagnosis of, 789. 

etiology of, 788. 

prognosis of, 789. 

symptoms of, 789. 

treatment of, 789. 
herpetica, 779. 

etiology of, 779. 

pathology of, 780. 

prognosis of, 780. 

symptomatology of, 780. 

treatment of, 780. 
hyphomycetica, 785. 
mycetogenetica, 784. 

diagnosis of, 786. 

pathology of, 785. 

prognosis of, 786. 

symptoms of, 786. 

treatment of, 786. 
ulcerosa, 781. 

diagnosis of, 783. 

etiology of, 781. 

pathology of, 782. 

prognosis of, 783. 

symptoms of, 782. 

treatment of, 783. 



1122 



INDEX. 



Sun and windows, 125. 

Supra-renal capsules, affections of the, 940. 

in tlie new-born infant, 44. 

normal development, 78. 
Sweat-glands in the new-born infant, 51. 

normal development, 110. 

of premature infants, 292. 
Sweet whey, 282. 

Syphilis, congenital, with enlarged spleen, 
367. 

dentition in, 493. 

diagnosis between, and meningitis, 
611. 

diagnosis of, 497. 

of hereditary, 496. 

digestive disturbances in, 493. 

early manifestations of hereditary, 
491. 

heart in, 490. 

haemorrhagica neonatorum, 494. 

hereditary, 487. 

insomnia in, 494. 

intra-cranial, 668. 
diagnosis of, 669. 
pathology of, 668. 
prognosis of, 670. 
symptoms of, 669. 
treatment of, 670. 

kidney in, 490. 

later manifestations of hereditary, 504. 

liver in, 489. 

lungs in, 490. 

miscarriage in, 503. 

mouth in, 494. 

nose in, 494. 

osseous system in, 490. 

pancreas in, 490. 

pathology of, 489. 

spleen in, 489. 

teeth in, 506. 

testicle in, 490. 

throat in, 490. 

thymus gland in, 490. 

treatment of, 498. 

of later symptoms of, 506. 

upper air-passages in, 490. 
Syphilitic dactylitis, 496. 

iritis, 493. 

kidney, 490. 

lesions of the mouth, 494. 

liver, 489. 

lung, 490. 

onychia, 506. 

osteochondritis, 495. 

pancreas, 490. 

spleen, 489. 



Syphilitic teeth, 508. 

testicle, 490. 

throat, 490. 

thymus gland, 490. 
Syringomyelia, 690. 
Syringo-myelocele, 420. 



T. 



Tables showing management of food and 

increase in weight, 264. 
Taeniae, 911. 
Tapeworms, 911. 
Taste in the new-born infant, 51. 
Teeth, effect of syphilis on the, 493, 506. 

in the new-born infant, 37. 

nonxial development of the, 68. 

syphilitic, 508. 
Temperature in the. new-born infant, 48. 

normal development of, 94. 

of premature infant, 297. 

of the sick child, 320. 
Temporary amnesia, 739. 
Testicles at end of term, 24. 

descent of the, 432. 

syphilitic, 490. 

tubercular disease of the, 945. 

tumors of the, 432, 946. 
Tetanus neonatorum, 452. 

etiology of, 452. 

symptoms of, 452. 

treatment of, 452. 
Tetany, 744. 

Third nutritive period, 287. 
Thorax in the new-born infant, 38. 

normal development of the, 70. 

of the premature infant, 291. 
Throat, examination of the, 323. 

in scarlet fever, 535, 556. 

syphilitic, 490. 
Thrombosis of the cerebral sinuses, 626. 
Thrush, 785. 

Thj-mus gland in the new-born infant, 
42. 

normal development of the, 72. 

syphilis of the, 490. 
Thyroid gland, diseases of the, 1095. 

enlargement of the, 1096. 

hyperaemia of the, 1095 

normal development of the. 111. 
Thyroiditis, 1096. 
Tinea, 460. 

circinata, 460. 

treatment of, 461. 

favosa, 461. 



INDEX. 



1123 



Tinea favosa, treatment of^ 461. 
tonsurans, 460. 
trichophytina, 460. 
Tongue-tie, 414. 
Tonsil, pharyngeal, 35, 66. 
hypertrophy of the, 806. 
diagnosis of, 806. 
etiology of, 806. 
pathology of, 806. 
prognosis of, 808. 
symptoms of, 806. 
treatment of, 809. 
Killian's observations on the, 36. 
Tonsillitis, acute, 809. 

diagnosis of, 811. 
prognosis of, 811. 
symptoms of, 810. 
treatment of, 811. 
chronic, 812. 

pathology of, 812. 
prognosis of, 813. * 

symptoms of, 813. 
treatment of, 813. 
Tonsils, faucial, 35. 
Touch in the new-horn infant, 51. 
Toys, 128. 

Trachea, diseases of the, 953. 
Tremor, 762. 
Tub, 129. 

Tubercular diseases of the intestines, 861. 
of the testicle, 945. 
meningitis, 603. 

infantile, 612. 
peritonitis, 921. 
Tuberculosis, acute miliary, 1090. 
chronic diffuse, 1090.^ 
chronic, of the lung, 996. 
diagnosis of, 996. 
prognosis of, 997. 
symptoms of, 996. 
treatment of, 997. 
of the liver, 915. 
of the lung, 993. 
etiology of, 993. 
pathology of, 993. 
of the skin, 485. 

treatment of, 486. 
the blood in miliary, 374. 
Tumors, intra-cranial, 662. 
pathology of, 662. 
symptoms of, 663. 
of the kidney, 939. 
of the testicle, 946. 
Typhoid fever, diagnosis between, and men- 
ingitis, 610. 
the blood in, 370. 



U. 

Ulcers of the stomach, 853. 
Umbilical arteries in the foetus, 20. 

post-natal change in the, 21. 
cord, hemorrhage of, 54. 

normal condition of, 24, 54. 
normal development of, 110. 
hernia, 426. 

congenital, into the cord, 425. 
vein, post-natal change in the, 21. 
Umbilicus, fungus of the, 425. 
Uric acid infarction in the new-born infant, 

44. 
Urine in the new-born infant, 53. 
in scarlet fever, 544. 
normal development of the, 111. 
of adolescence, 114. 
Urticaria, treatment of, 467. 
Uterus in the new-born infant, 48. 
Uvula, elongation of the, 816. 



V. 

Yaccination, abnormal effects of, 152. 

efflorescence of, 523. 

evolution of, 151. 

method of, 150. 

statistics of, 147. 
Vaccinia, 152, 523. 

efflorescence of, 523. 
Vagina, occlusion of the, 435. 

reflex of the, 752. 
Varicella, 524. 

complications of, 526. 

diagnosis of, 527. 

efflorescence of, 525. 

gangrenous, 526. 

incubation of, 525. 

pathology of, 525. 

prodromata of, 525. 

prognosis of, 526. 

symptoms of, 525. 

treatment of, 531. 
Variola, 516. 

blood in, 371. 

confluent, 521. 

complications of, 522. 

desquamation of, 521. 

diagnosis of, 522. 

discrete, 520. 

efflorescence of, 521. 

hemorrhagic, 521. 

incubation of, 520. 

modified form of, 522. 

pathology of, 518. 



1124 



INDEX. 



Variola, prodromata of, 520. 

svmptor^'^- ^-p, 520 

t,. , -.--^. 

Veins xu /-born infant, 43. 

Ventilation m the nursery, 127. 
Ventilator, 248. 

window, 127, 130. 
Vermiform appendix, normal development 

of the, 92. 
Vernix caseosa, description of, 23. 
Verruca, 480. 
Vertebrae, position of, in the new-born infant, 

37. 
Vertigo, 743. 

Vitality in the new-born infant, 49. 
Voice in the new-born infant, 51. 

normal development of the, 110, 
Volvulus, 876. 
Vomiting, 840. 

diagnosis of, 842. 

etiology of, 841. 

prognosis of, 842. 

symptoms of, 841 

treatment of, 842. 
Vulvo-vaginitis, 943. 

pathology of, 943, 



Vulvo-vaginitis, prognosis of, 944. 
symptoms of, 944. 
treatment of, 944. 

W. 

Walls in the nursery, 126. 

Warts, 480. 

Wash-room, 253. 

Weaning, 206, 284. 

Weighing of premature infants, 301. 

Weight in the new-born infant, 49, 

normal development of, 97, 

of premature infant, 290, 
Wet-nurses, 209, 211. 

diet of, 212. 
Wheat, 282, 
Whey, sweet, 282, 
Whooping-cough, 998. 
Windows, sun, and in the nursery, 125. 
Worcester, Dr. Alfred, brooder, 309, 

incubator, 306. 
Writing, mirror, 673, 



Yellow atrophy, acute, of the liver, 915. 



THE END. 



906 



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